[Congressional Record Volume 156, Number 43 (Sunday, March 21, 2010)]
[House]
[Pages H1891-H2169]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
[[Page H1891]]
Senate
The Senate was not in session today. Its next meeting will be held on
Monday, March 22, 2010, at 2 p.m.
House of Representatives
Sunday, March 21, 2010
SENATE AMENDMENTS TO H.R. 3590, SERVICE MEMBERS HOME OWNERSHIP TAX ACT
OF 2009, AND H.R. 4872, HEALTH CARE AND EDUCATION RECONCILIATION ACT OF
2010--Continued
{time} 2145
Mr. CAMP. Mr. Speaker, for the purposes of a unanimous consent
request, I yield to the gentleman from Texas (Mr. Hall).
(Mr. HALL of Texas asked and was given permission to revise and
extend his remarks.)
Mr. HALL of Texas. Mr. Speaker, I rise in opposition to this flawed
health care bill.
Mr. CAMP. Mr. Speaker, for the purpose of a unanimous consent
request, I yield to the gentlewoman from North Carolina (Ms. Foxx).
(Ms. FOXX asked and was given permission to revise and extend her
remarks.)
Ms. FOXX. Mr. Speaker, I rise in opposition to this flawed health
bill.
Mr. CAMP. For the purpose of a unanimous consent request, I yield to
the gentleman from New York (Mr. King).
(Mr. KING of New York asked and was given permission to revise and
extend his remarks.)
Mr. KING of New York. Mr. Speaker, I rise in opposition to this
flawed health care bill.
Mr. CAMP. Mr. Speaker, I yield 4 minutes to the distinguished
gentleman from Virginia (Mr. Cantor), the Republican whip.
Mr. CANTOR. Mr. Speaker, all of us in this body, Republicans and
Democrats alike, care about Americans' health care, but many of us from
both sides of the aisle don't care for this trillion dollar overhaul.
And the fact is, the majority of Americans don't care for it either.
Sadly, Mr. Speaker, the only bipartisanship we've seen surrounding
this overhaul has been in opposition to it, and there's a reason for
that. Health care is a very personal issue, and this overhaul will
impact every man, woman, and child in this country. It will even affect
future generations that have not yet been born.
Mr. Speaker, this overhaul will have a huge impact on our parents,
our spouses, and our kids. This is something that they'll be paying for
for the rest of their lives. And for too long, Mr. Speaker, the
majority in this body and the President of the United States have
refused to listen to the American people.
So, Mr. Speaker, I have a message for those Americans. We hear you.
We hear you loud and clear, because we believe this government must
stop spending money that it doesn't have, and this trillion dollar
overhaul will do the opposite.
We believe that this government must stop piling debt upon our
children and grandchildren, and this trillion dollar overhaul will do
the opposite.
We believe that this government must stop raising taxes on small
businesses and families, and, Mr. Speaker, this trillion dollar
overhaul will do the opposite.
We believe that America is the land of innovation and that government
must stop crippling job creators and entrepreneurs with oppressive
mandates and taxes, and this trillion dollar overhaul will do the
opposite.
Mr. Speaker, we believe that in America our government must not force
those who fundamentally object to abortion to have to pay for it, and
this trillion dollar overhaul does the opposite.
And we believe in building upon what works in our current health
care, Mr. Speaker, so that doctors in America can continue to provide
the best care in the world, and this trillion dollar overhaul does the
opposite.
And, Mr. Speaker, we believe that families and patients should have
the freedom and the right to choose the doctors they want, and this
trillion dollar overhaul will begin to take that freedom away.
Mr. Speaker, if there's one thing that the American people have
learned over the past year, it's that we are truly at a critical time
in this country. We are at a crossroads.
This trillion dollar health care overhaul before us today has caused
a lot of fear and uncertainty. It's the latest part of an agenda that
is being forced upon the American people that attempts to seize more
control over the economy and our lives.
The choices we make on deficit spending, higher taxes, energy
security, and health care, they're all important. They're important
because they will all determine what kind of country we want to be.
[[Page H1892]]
The SPEAKER pro tempore (Mr. Obey). The time of the gentleman has
expired.
Mr. CAMP. I yield the gentleman 30 additional seconds.
Mr. CANTOR. Mr. Speaker, the choice before us is very clear. The
choice is whether we want to become a country that is unrecognizable,
or one that will fulfill the American Dream so that we remain the most
secure and most prosperous, freest country in the history of the world.
Mr. Speaker, I urge my colleagues today to listen to the people and
vote ``no'' against this legislation.
Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request,
I yield to Mr. Ackerman of New York.
(Mr. ACKERMAN asked and was given permission to revise and extend his
remarks.)
Mr. ACKERMAN. I rise in enthusiastic support of this historic,
important bill.
The SPEAKER pro tempore. The gentleman will be charged.
Mr. SPRATT. For purposes of another unanimous consent request, I
yield to the gentlelady from California (Ms. Waters).
(Ms. WATERS asked and was given permission to revise and extend her
remarks.)
Ms. WATERS. Mr. Speaker, I rise in support of this bill.
Our health care system is broken; no one can deny it.
Every day, millions of Americans go without needed health care
because they have no insurance. Some of these people work for small
businesses and other employers that do not provide insurance. Some of
them lost their insurance when they lost their jobs. Some of them were
denied coverage by insurance companies because of a pre-existing
condition. And some of them simply could not afford the escalating
premiums. Even for people with health insurance, a devastating accident
or illness can be very expensive. The cost of health care is the number
one reason for bankruptcies in America.
So we cannot afford inaction. Today, we have a clear choice--to start
to fix the broken health care system--or to do nothing.
However, this bill is not perfect. I would like to have seen included
measures such as a public health insurance option like Medicare that
would compete with the private insurance plans and a single national
insurance exchange where people could purchase the health plan of their
choice instead of separate state-based exchanges with different
standards. I believe these measures would be more effective at
containing costs and creating competition for the insurance industry.
I am also concerned that this bill should not be used to limit the
right of women to reproductive choice. Despite the President's
Executive Order, attempting to codify existing law under the so-called
Hyde Amendment, it is not clear that the Senate bill does not go beyond
the Hyde amendment.
Nevertheless, I have decided to support H.R. 3590, together with the
improvements included in H.R. 4872, because it will make health care
more affordable and more accessible for thousands of my constituents
and millions of Americans. By passing this legislation today we are
taking a critically important step in the right direction.
According to an analysis by the House Energy and Commerce Committee,
this health care reform bill will benefit California's 35th District in
the following ways:
Improve coverage for 281,000 residents with health insurance.
Extend coverage to 125,500 residents who lack insurance.
Guarantee that 21,200 residents with pre-existing conditions can
obtain coverage.
Allow 58,000 young adults to obtain coverage on their parents'
insurance plans.
Give tax credits and other assistance to up to 157,000 families and
15,100 small businesses to help them afford coverage.
Improve Medicare for 62,000 beneficiaries, including reducing the
costs of prescription drugs and closing the donut hole.
Protect 1,100 families from bankruptcy due to unaffordable health
care costs.
Provide millions of dollars in new funding for 10 community health
centers.
Reduce the cost of uncompensated care for hospitals and other health
care providers by $15 million annually.
Many provisions of the bill will kick in immediately. Insurance
companies will no longer be able to take away a person's insurance
because the person gets sick, an unfair practice known as rescission.
It will immediately prevent insurance companies from denying coverage
to children with pre-existing conditions, and eventually end
discrimination against anyone with a pre-existing condition. It will
immediately allow young people the ability to remain on their parents'
insurance until age 26. It will immediately help seniors pay for
prescription drugs and eventually eliminate the donut hole completely.
And it will extend tax credits to small businesses so that they can
provide health insurance to their employees.
Over the next few years, the bill will extend coverage to 32 million
Americans, or 95 percent of the population, providing affordability
credits for individuals who cannot afford to purchase health insurance
on their own.
Improving our health care system is essential to setting us on the
right path to healthier lives, renewed American innovation, and a
stronger, more stable American economy. I urge my colleagues to support
this bill and expand access to health care for families and small
businesses throughout the United States of America.
Mr. SPRATT. For purposes of a unanimous consent request, I yield to
Mr. Driehaus from Ohio.
(Mr. DRIEHAUS asked and was given permission to revise and extend his
remarks.)
Mr. DRIEHAUS. Mr. Speaker, I rise in support of this health care
legislation.
Mr. SPRATT. Mr. Speaker, I now yield 1 minute to the gentlelady from
Minnesota (Ms. McCollum).
Ms. McCOLLUM. Mr. Speaker, beyond the walls of this Capitol, there
are millions of Americans who can't afford health insurance and they
live in fear of getting sick. Millions more are discriminated against
by insurance companies because they have preexisting medical
conditions.
In my own life, as a child and as an adult, I've lived without health
insurance. A dear, dear niece of mine has a preexisting condition that
makes her uninsurable.
Passing health insurance reform is not a political game. It's
personal. It's about real people's lives. When we pass this bill, we
will save lives. Families will be protected. Millions of Americans will
no longer live in fear.
Today I will vote to end discrimination against people with
preexisting conditions. Today I will vote to extend health care to 32
million Americans. And when this bill becomes law, health care security
will finally become a reality for the American people.
Mr. CAMP. Mr. Speaker, at this time I will yield to the gentleman
from California for the purpose of a unanimous consent request.
Mr. DANIEL E. LUNGREN of California. Mr. Speaker, because of
confusion over its legal effect, I ask unanimous consent that the text
of President Obama's Executive order referring to abortion funding,
that it be considered as a freestanding amendment to the text of H.R.
3590 and we be allowed to vote on it separately.
The SPEAKER pro tempore. The Chair cannot entertain such a request
unless it has been cleared.
Parliamentary Inquiries
Mr. DANIEL E. LUNGREN of California. Mr. Speaker, parliamentary
inquiry.
The SPEAKER pro tempore. The gentleman will state his parliamentary
inquiry.
Mr. DANIEL E. LUNGREN of California. Mr. Speaker, is such unanimous
consent request, is it, in fact, in order under the rules of the House?
The SPEAKER pro tempore. The Chair has indicated that requests for
these matters must be cleared.
The Chair is not obligated to instruct Members on the rules of the
House.
Mr. DANIEL E. LUNGREN of California. Mr. Speaker, with respect, may I
make a further inquiry, Mr. Speaker?
The SPEAKER pro tempore. The gentleman may inquire.
Mr. DANIEL E. LUNGREN of California. Would that request, if it were
cleared, be considered germane to the bill under consideration?
The SPEAKER pro tempore. The Chair will not respond to hypotheticals.
Mr. DANIEL E. LUNGREN of California. Mr. Speaker, additional
parliamentary inquiry.
The SPEAKER pro tempore. The gentleman may proceed.
Mr. DANIEL E. LUNGREN of California. When I am informed that it must
be cleared, do I understand that to mean it must be cleared by the
Speaker or the majority leader?
The SPEAKER pro tempore. Leadership on both sides must clear these
matters. I'm sure the gentleman knows that.
Mr. DANIEL E. LUNGREN of California. I thank the Speaker.
Mr. CAMP. Mr. Speaker, I reserve my time.
[[Page H1893]]
Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request,
I yield to the gentlewoman from Ohio (Ms. Kaptur).
(Ms. KAPTUR asked and was given permission to revise and extend her
remarks.)
Ms. KAPTUR. Mr. Speaker, I rise in support of affordable health
insurance for all Americans.
I rise in support of this historic legislation because affordable
health care is really about life--about a healthier and more secure
life for all Americans.
This is about life--the life of a senior who can't afford
prescription drugs, or a mother carrying a new life waiting to be born.
This legislation says every American has the right to the dignity of
a healthy life. Nothing more, nothing less. Its promise is true for all
citizens, of all ages, from all walks of life. In that respect, it is
profoundly American.
It is most certainly about the millions of citizens in our nation who
run small businesses and about their employees--who after all these
years comprise over half the uninsured in our nation. These businesses
embody the hopes and dreams of life in America. They are the engines of
job growth, but after all these decades, they are treated like second
class citizens.
This bill is about women and children--the millions of women who have
no health care and the millions of children who are born frail and weak
because their mothers have no access to prenatal care and their fathers
have no insurance. The March of Dimes tells us that every year, more
than half a million American children are born underweight, one out of
every eight children born premature, malnourished, and so many with
disability. That should not happen in America. Our nation's insurance
programs aren't meeting the market nor the promise of America.
This legislation will help millions of women obtain health coverage
and thus reduce abortion by enhancing broad coverage options for
women's and children's health. It will vastly improve preventive care,
more than double funds available to community health centers (including
obstetric and gynecological care), and move America fully into this
21st century. No woman, no woman--including poor women, pregnant women,
working women, single women, and nursing women--will be denied health
insurance coverage.
Mr. Speaker, the best anti-abortion bill we can pass is one that
gives women and children a real chance through health insurance
coverage that allows fragile life to come to term. This bill does that.
It gives hope, to every family, to every woman to every child yet to be
born. It says you have a right to be born. It provides for prenatal
care during a woman's pregnancy, preventive care for newborns, funding
to help pregnant and parenting teens and college students with
assistance for basic necessities, as well as adoption tax credits. No
family, no mother, no father will ever have to question again whether
they can afford to bring a conceived child to term
This bill is about a better life for seniors, too. By closing the
doughnut hole, it makes sure they can afford the medicine they need to
live healthy, independent lives.
As the costs of insurance have risen, emptying the wallets of our
neighbors, almost one in three Americans (87 million of our fellow
citizens) went without health insurance for some period last year. We
can do better in America.
There is so much shifting in the marketplace, it is becoming less
stable and reliable. Thousands more of our citizens are losing their
insurance because they have lost their jobs as the unemployment
epidemic rages throughout our nation.
Even those with insurance, no matter how expensive or robust it might
be, learn their coverage is not guaranteed nor continuous nor quality.
Millions of hardworking Americans are denied coverage; charged an
impossibly higher rate, or discriminated against because of a pre-
existing condition. Family employer-sponsored health insurance
increased 119 percent over the last decade. Small business premiums
alone have risen 129 percent. Without reform, rates are projected to
increase to $23,842 on average by 2020. This simply cannot continue;
the system is broken.
I can identify with the tens of millions of our fellow citizens who
have no health insurance, over half of whom are either small business
owners or their employees. When my brother, Steve, and I were growing
up, our beloved, hardworking father, ``Kappy,'' had three heart
attacks. He made the gut-wrenching decision to sell our small family
market to go to work in an auto plant for one reason: to get health
insurance for his wife, Anastasia, and their two children. He didn't
even care about himself. I shall never forget that piercing experience:
it is the story of millions upon millions of our fellow citizens
excluded, priced out or eliminated from the insurance market place. In
our parents' memory, the best jobs bill I can vote is one that takes
the health insurance anxiety off the backs of small businesspeople
across our nation. I do so today in our parents' memory.
I have listened closely to the concerns of citizens in Ohio's Ninth
Congressional District. There is passion on both sides. Some claim this
legislation is unconstitutional. I respectfully disagree. To accept
that argument is to say that Social Security is unconstitutional, or
Medicare is unconstitutional, or veterans' benefits are
unconstitutional, or the interstate highway system is unconstitutional.
I believe that argument would tear apart the fabric of our Republic.
Affordable health insurance reform is necessary to provide greater
competition among available plans to cut the costs of doing business,
reduce the share of government expenditures spent on health care, help
our companies to be more competitive in the world market, unleash the
entrepreneurial talents of the American people, and give peace of mind
to the middle class, our seniors and others that everything they have
worked for will not be taken away if they get sick.
I have been touched by stories from constituents and I rise today in
support of this historic bill for them:
David owns a small business. In 1999, he offered health insurance to
his 15 employees. Over the course of the next decade, his insurance
premiums skyrocketed and he had to let some employees go. By 2007 he
was down to three employees and could no longer provide insurance for
them--or himself. Now uninsured, he recently suffered a heart attack.
Health care expenses forced him to file for bankruptcy. Sad to say, his
case is not all that unusual--health care costs are the leading cause
of bankruptcy in America.
Jeff changed jobs and was required to obtain different health
insurance while his wife was mid-term in a pregnancy. The pregnancy was
high risk, the birth was problematic, and the insurer, a ``health
maintenance organization,'' an HMO, denied coverage not only for the
mother's labor and delivery, but also their baby's conditions at birth.
Lillian will reach her allowable Part D private drug plan coverage in
March. She cannot afford to pay for her medicines, so she never climbs
out of the ``doughnut hole'' to obtain coverage again. As a result, she
will quit taking her prescription drugs for nine months, until the new
year starts. As a result, she has been hospitalized.
Mary has suffered from bipolar disorder since her twenties. She is
now in her fifties. She is married, with a family. She has experienced
many exacerbations of her illness and resulting hospitalizations. She
reached the insurer's lifetime maximum when in her early forties. Since
then, her family has had to pay her expenses.
Susan is the director of a nonprofit organization that serves
homeless families. The organization offers health insurance to
employees, but the premium increase this year was 49%. Now the agency
must choose between dropping insurance as an employee benefit or
reducing services to the vulnerable families it serves. Meanwhile, the
insurer posted record profits last year.
Bob and Catherine were married for 53 years and raised six children.
Catherine developed a chronic debilitating illness which worsened over
time. Bob took care of her at home for nine years, using all of their
savings and having to sell their house.
Cassandra is a12-year-old girl with juvenile diabetes. Since her
diagnosis as a toddler, her parents have been unable to obtain health
care coverage even though they could afford to pay for it. They must
pay all her health expenses out of pocket. They live in a small
apartment.
Aaron is 14. He has a failing liver and has needed a liver transplant
for five years. His mom could not work because she had to care for him.
The family has no health care coverage. Though the hospital absorbed
much of the cost for his care and treatment, the family held
fundraisers through the years to pay for his transplant and the health
care which has subsequently followed. All of us are familiar with the
spaghetti dinners, and benefit dances, and silent auctions to help
families in similar circumstances. Heroic compassionate people rise to
the occasion in communities across our nation, but often it simply is
not enough.
For too long, the health of our nation has dwindled--indeed the U.S.
ranks behind over a dozen major nations in health outcomes--while the
pockets of the insurance giants have thickened. Insurance companies
raise rates and deny coverage to pay their CEOs excessive salaries and
bonuses. WellCare and Aetna's executives, for example, received between
$18 and $23 million dollars alone in 2008. Despite wanting to increase
premiums recently for individuals by 39 percent, WellPoint's
executives, which is an insurance provider in the state of Ohio where I
represent, received over $8.6 million.
Our seniors have compromised prescription drugs for necessary
groceries, while the insurance and pharmaceutical industries have made
record profits. Hard working families
[[Page H1894]]
have watched their savings plummet and their homes foreclosed after
unexpected illnesses. Women with breast cancer, men with heart disease
and children with leukemia or childhood diabetes have been flat-out
denied health insurance coverage for pre-existing conditions or
reaching insurance policy caps.
With the mounting economic strain on American families and the rising
costs of health insurance to workers, businesses and the federal
budget, the status quo has proven itself unsustainable, fiscally
irresponsible and morally unacceptable. The time has come for this
historical change. The bill before us pays for itself and actually
brings revenues back to the health system as a result of the
combination of added competition and better use of the health dollar. I
stand in support of its promise to the American people--the promise of
a better and healthier life for all in this blessed land.
Mr. SPRATT. Also for purposes of a unanimous consent request, I yield
to Mrs. Dahlkemper from Pennsylvania.
(Mrs. DAHLKEMPER asked and was given permission to revise and extend
her remarks.)
Mrs. DAHLKEMPER. Mr. Speaker, I rise in support of this health care
legislation.
Mr. SPRATT. I now yield 1\1/2\ minutes to the gentlewoman from
Connecticut (Ms. DeLauro).
Ms. DeLAURO. Mr. Speaker, I rise in support of this historic
legislation, arguably the most important vote we here today will ever
take in this Chamber.
Today fulfills a promise made 100 years ago by Theodore Roosevelt
when he first called for comprehensive health insurance reform. It
fulfills a promise made by Franklin Roosevelt to our parents, our
grandparents, our great grandparents in 1944. President Richard Nixon
also labored and lost on this national mission. And President Bill
Clinton, too, tried to climb this mountain.
Today's legislation builds on the great achievements of Social
Security and Medicare, those big changes that we all take for granted,
regardless of party. And yes, they, too, were characterized as
socialist government takeovers.
And today we have a chance to make health insurance affordable for
people and for small businesses that ends the power of the insurance
companies to deny them coverage, increase their rates and, yes, drop
them when they get sick. Enough.
This reform law allows 32 million of our citizens to get insurance, a
moral imperative. It closes the doughnut hole in prescription drugs for
seniors, and women will no longer have to pay more for their insurance,
a long overdue reckoning.
I am humbled by the opportunity to cast a vote for this historic
change.
Mr. CAMP. Mr. Speaker, I yield myself 2 minutes.
We've heard a lot of discussion tonight about this bill and how it's
been characterized. Let me just read a few quotes from my friends on
the Democratic side who've characterized this bill.
A Democrat from North Carolina says: There is no question that our
current health care system is broken and that we need to make
significant reforms to improve it in an equitable, fiscally
responsible, and sustainable manner. In my opinion, the bill as written
does not meet those criteria.
A Democrat from Tennessee says: After thorough and careful review of
the legislation, I am unconvinced that the long-term trend of rising
health care costs is adequately addressed and am, therefore, unable to
support the legislation.
A Democrat from New Mexico said: I do not believe that the bill does
enough to contain costs.
A Democrat from North Carolina says: Health care reform is needed,
but the bill before us is too expensive, does not adequately address
rising medical costs and skyrocketing insurance premiums, and tries to
do too much too soon. We simply cannot afford to create a new Federal
bureaucracy that costs nearly $1 trillion when our national debt is $12
trillion and there is no plan in place to address it. I will not vote
for it.
Another Democrat from Virginia says: I have spoken with countless
small business owners, families, medical professionals, and average
citizens across Virginia, and it becomes very clear that this bill is
not the right solution for Virginia's health care challenges.
On and on and on again. This is not the right bill for America. This
costs $1 trillion, raises a half a trillion in taxes, and cuts Medicare
by half a trillion dollars. Vote ``no'' on this bill.
{time} 2200
Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request,
I yield to the gentlelady from New York (Mrs. Lowey).
(Mrs. LOWEY asked and was given permission to revise and extend her
remarks.)
Mrs. LOWEY. I rise in strong support of this bill.
Mr. Speaker, I rise in support of enacting historic health care
reform.
Over the past fifteen months, I have held countless meetings with
community organizations, small business owners, senior citizens,
doctors, nurses, and patients, joined public forums and community
meetings, and held telephone town halls. It is clear to me the status
quo is unsustainable. Without action, individuals would continue to be
denied coverage and care, more families would go into bankruptcy due to
the costs of care, and businesses would continue to struggle to cover
their employees.
Some benefits will be evident almost immediately after this bill is
signed. The most egregious practices of insurance companies, like
denying coverage for children due to pre-existing conditions and
dropping coverage when patients become sick, will be illegal. Small
businesses will gain tax credits to provide affordable insurance to
their employees. Senior citizens will benefit from immediate steps to
close the Medicare prescription drug ``donut hole.''
I have heard hundreds of personal stories. A social worker in Ardsley
earning $53,000 per year whose out-of-pocket insurance premium just
increased by $110 to $831 per month. Or the man from White Plains who
was denied life saving cancer medication by his insurance company until
my intervention. The small business owner from Ossining whose premium
costs increased 40 percent this year.
I want to assure you that:
Medicare benefits will be strengthened by closing the prescription
drug ``donut hole,'' eliminating charges for preventive care, and
extending the solvency of the Medicare Trust Fund.
The vast majority of families in Westchester and Rockland Counties
will see absolutely no change in their income taxes due to this bill. I
fought to protect our region, and I continue my work to index federal
taxes to cost of living, which would help residents in our expensive
area.
Small businesses with fewer than 50 employees are exempt from
employer requirements and some will immediately be offered tax credits
to provide coverage for their employees.
This legislation will not provide taxpayer funding for abortion, and
in fact I am not pleased with new obstacles to reproductive health
care.
And finally, this bill will reduce the federal deficit by more than
$143 billion in the first ten years and more than $1.2 trillion in the
second ten years after passage.
Instead of passing the House bill, the Senate adopted a flawed bill
that I will support for the sole purpose of immediately making
improvements through reconciliation to help American families and
businesses.
Although the legislation we passed this week is not perfect, it will
rein in skyrocketing insurance premiums for families, prevent the worst
practices of the insurance industry, help 30 million uninsured
Americans gain access to care, allow insured Americans to keep their
coverage if they like it, help small businesses afford coverage for
their employees, allow children up to 26 years old to stay on their
parents' plans and protect Medicare for senior citizens.
Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request,
I yield to the gentleman from New Jersey (Mr. Payne).
(Mr. PAYNE asked and was given permission to revise and extend his
remarks.)
Mr. PAYNE. Mr. Speaker, I rise in support of this great health care
reform bill.
Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request,
I yield to the gentleman from Florida (Mr. Grayson).
(Mr. GRAYSON asked and was given permission to revise and extend his
remarks.)
Mr. GRAYSON. I rise in support of this bill.
Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request,
I yield to the gentleman from Georgia (Mr. Bishop).
[[Page H1895]]
(Mr. BISHOP of Georgia asked and was given permission to revise and
extend his remarks.)
Mr. BISHOP of Georgia. I rise in support of this historic health care
reform bill.
Mr. SPRATT. Mr. Speaker, can you tell me how much time is remaining
on my side?
The SPEAKER pro tempore. There are 2\1/4\ minutes remaining for the
gentleman from South Carolina.
Mr. SPRATT. Mr. Speaker, I yield 1\1/4\ minutes to the gentleman from
New Jersey (Mr. Andrews).
(Mr. ANDREWS asked and was given permission to revise and extend his
remarks.)
Mr. ANDREWS. Mr. Speaker, our friends on the other side of the aisle
have asked frequently tonight what kind of country are we. They've
asked exactly the right question. Tomorrow when a person is denied a
job because she has breast cancer or is charged higher premiums because
he has asthma, what kind of country will we be? Tomorrow when a senior
citizen has enough money in her checking account to pay the utility
bill or her prescription bill but not both, what kind of country will
we be? When a person who tonight is scrubbing floors or pumping gas or
waiting on tables tomorrow tries to go to buy a health insurance policy
for herself or her children, what kind of country will we be?
For Social Security, we gave decency for seniors. In Medicare, we
gave compassion for seniors. In the Civil Rights Act, we gave equality
for all Americans. Tonight, we will give justice and decency. That's
the kind of country that we will be.
Mr. CAMP. Mr. Speaker, at this time I yield 1 minute to the
distinguished minority leader, the gentleman from Ohio (Mr. Boehner).
Mr. BOEHNER. Mr. Speaker and my colleagues, I rise tonight with a sad
and heavy heart. Today we should be standing together reflecting on a
year of bipartisanship and working to answer our country's call and
their challenge to address the rising costs of health insurance in our
country.
Today, this body, this institution, enshrined in the first article of
the Constitution by our Founding Fathers as a sign of the importance
they placed on this House, should be looking with pride on this
legislation and our work.
But it is not so.
No, today we're standing here looking at a health care bill that no
one in this body believes is satisfactory. Today we stand here amidst
the wreckage of what was once the respect and honor that this House was
held in by our fellow citizens. And we all know why it is so. We have
failed to listen to America. And we have failed to reflect the will of
our constituents. And when we fail to reflect that will, we fail
ourselves, and we fail our country.
Look at this bill. Ask yourself, do you really believe that if you
like the health plan that you have that you can keep it? No, you can't.
You can't say that.
In this economy, with this unemployment, with our desperate need for
jobs and economic growth, is this really the time to raise taxes, to
create bureaucracies, and burden every job creator in our land? The
answer is no.
Can you go home and tell your senior citizens that these cuts in
Medicare will not limit their access to doctors or further weaken the
program instead of strengthening it? No, you cannot.
Can you go home and tell your constituents with confidence that this
bill respects the sanctity of all human life and that it won't allow
for taxpayer funding of abortions for the first time in 30 years? No,
you cannot.
And look at how this bill was written. Can you say it was done
openly, with transparency and accountability? Without backroom deals
and struck behind closed doors hidden from the people? Hell, no, you
can't.
Have you read the bill? Have you read the reconciliation bill? Have
you read the manager' s amendment? Hell, no, you haven't.
Announcement by the Speaker Pro Tempore
The SPEAKER pro tempore. Both sides would do well to remember the
dignity of the House.
Mr. BOEHNER. Mr. Speaker, in a few minutes we will cast some of the
most consequential votes that any of us will ever cast in this Chamber.
The decision we make will affect every man, woman, and child in this
Nation for generations to come. If we're going to vote to defy the will
of the American people, then we ought to have the courage to stand
before them and announce our votes, one at a time.
I sent a letter to the Speaker this week asking that the ``call of
the roll'' be ordered for this vote. Madam Speaker, I ask you, will
you, in the interest of this institution, grant my request?
Will you, Mr. Speaker, grant my request that we have a call of the
roll?
The SPEAKER pro tempore. Is the gentleman asking a rhetorical
question?
Mr. BOEHNER. Mr. Speaker, will you grant my request that we have a
call of the roll?
The SPEAKER pro tempore. Under clause 2(a) of rule XX, a record vote
is conducted by electronic device unless the Speaker directs otherwise.
MR. BOEHNER. And you, Mr. Speaker, will you grant that request?
The SPEAKER pro tempore. The Chair will decide at the time the
question is ripe. This is not it.
Mr. BOEHNER. My colleagues, this is the People's House.
When we came here, we each swore an oath to uphold and abide by the
Constitution as representatives of the people. But the process here is
broken. The institution is broken. And as a result, this bill is not
what the American people need nor what our constituents want.
Americans are out there making sacrifices and struggling to make a
better future for their kids, and over the last year as the damn-the-
torpedoes outline of this legislation became more clear, millions of
Americans lifted their voices and many, for the first time, asking us
to slow down, not to try to cram through more than this system could
handle, not to spend money that we didn't have. In this time of
recession, they wanted us to focus on jobs, not more spending, not more
government, and certainly not more taxes.
But what they see today frightens them. They're frightened because
they don't know what comes next. They're disgusted because what they
see is one political party closing out the other from what should be a
national solution. And they're angry. They're angry that no matter how
they engage in this debate, this body moves forward against their will.
Shame on us. Shame on this body. Shame on each and every one of you
who substitutes your will and your desires above those of your fellow
countrymen.
Around this Chamber, looking upon us are the lawgivers from Moses, to
Gaius, to Blackstone, to Thomas Jefferson. By our actions today, we
disgrace their values. We break the ties of history in this Chamber. We
break our trust with America.
When I handed the Speaker the gavel in 2007, I said this: ``This is
the People's House. And the moment a majority forgets it, it starts
writing itself a ticket to minority status.''
If we pass this bill, there will be no turning back. It will be the
last straw for the American people. In a democracy, you can only ignore
the will of the people for so long and get away with it. And if we defy
the will of our fellow citizens and pass this bill, we're going to be
held to account by those who have placed us in their trust. We will
have shattered those bonds of trust.
I beg you, I beg each and every one of you on both sides of the
aisle: Do not further strike at the heart of this country and this
institution with arrogance, for surely you will not strike with
impunity.
I ask each of you to vow to never let this happen again--this
process, this defiance of our citizens. It's not too late to begin to
restore the bonds of trust with our Nation and return comity to this
institution.
And so join me. Join me in voting against this bill so that we can
come together, together anew and addressing the challenge of health
care in a manner that brings credit to this body and brings credit to
the ideals of this Nation, and most importantly, that reflects the will
of the American people.
{time} 2215
Mr. SPRATT. Mr. Speaker, I yield 1 minute to the gentlewoman from
California, who has led the way in this quest for health care reform
and tirelessly, persistently, she has brought us to this moment of the
decision, the
[[Page H1896]]
gentlewoman from California, the Speaker of the House, Ms. Pelosi.
Ms. PELOSI. Thank you, my colleagues. I thank the gentleman for
yielding. I thank all of you for bringing us to this moment.
Mr. Speaker, it is with great humility and with great pride that
tonight we will make history for our country and progress for the
American people. Just think, we will be joining those who established
Social Security, Medicare, and now tonight health care for all
Americans.
In doing so, we will honor the vows of our Founders, who, in the
Declaration of Independence, said that we are endowed by our Creator
with certain inalienable rights and among these are life, liberty, and
the pursuit of happiness.
This legislation will lead to healthier lives, more liberty to pursue
hopes and dreams and happiness for the American people. This is an
American proposal that honors the traditions of our country.
We would not be here tonight for sure without the extraordinary
leadership and vision of President Barack Obama. We thank him for his
unwavering commitment to health care for all Americans. This began over
a year ago under his leadership in the American Recovery and
Reinvestment Act where we had very significant investments in science,
technology, and innovation for health care reform.
It continued in the President's budget a few months later, a budget
which was a statement of our national values, which allocated resources
that were part of our value system and in a way that stabilized our
economy, created jobs, lowered taxes for the middle class and did so
and reduced the deficit and did so in a way that had pillars of
investment, including education and health care reform.
Health care reform and education equal opportunity for the American
people. This legislation tonight, if I had one word to describe it,
would be opportunity with its investments in education and health care
as a continuation of the President's budget.
We all know, and it's been said over and over again, that our economy
needs something new, a jolt, and I believe that this legislation will
unleash tremendous entrepreneurial power into our economy. Imagine a
society and an economy where a person could change jobs without losing
health insurance, where they could be self-employed or start a small
business.
Imagine an economy where people could follow their passions and their
talent without having to worry that their children would not have
health insurance, that if they had a child with diabetes who was
bipolar or preexisting medical condition in their family, that they
would be job locked. Under this bill, their entrepreneurial spirit will
be unleashed.
We all know that the present health care system and health insurance
system in our country is unsustainable. We simply cannot afford it. It
doesn't work for enough people in terms of delivery of service, and it
is bankrupting the country with the upward spiral of increasing medical
cost. The best action that we can take on behalf of America's family
budgets and on behalf of the Federal budget is to pass health care
reform.
The best action we can take to strengthen Medicare and improve care
and benefits for our seniors is to pass this legislation tonight, pass
health care reform. The best action we can do to create jobs and
strengthen our economic security is pass health care reform.
The best action we can take to keep America competitive, ignite
innovation, again, unleash entrepreneurial spirit is to pass health
care reform.
With this action tonight, with this health care reform, 32 million
more Americans will have health care insurance and those who have
insurance now will be spared of being at the mercy of the health
insurance industry with their obscene increases in premiums, their
rescinding of policies at the time of illness, their cutting off of
policies even if you have been fully paying but become sick. The list
goes on and on about the health care reforms that are in this
legislation: insure 32 million more people, make it more affordable for
the middle class, end insurance company discrimination on preexisting
conditions, improve care and benefits under Medicare and extending
Medicare solvency for almost a decade, creating a healthier America
through prevention, through wellness and innovation, create 4 million
jobs in the life of the bill and doing all of that by saving the
taxpayer $1.3 trillion.
Another Speaker, Tip O'Neill, once said, All politics is local. I say
tonight that when it comes to health care for all Americans, all
politics is personal. It's personal for the family that wrote to me,
who had to choose between buying groceries and seeing a doctor. It's
personal to the family that was refused coverage because their child
had a preexisting condition, no coverage, the child got worse, sicker.
It's personal for women. After we pass this bill, being a woman will
no longer be a preexisting medical condition.
It's personal for the senior gentleman whom I met in Michigan who
told me about his wife who had been bedridden for 16 years. He told me
he didn't know how he was going to be able to pay his medical bills. As
I said to you before, I saw a grown man cry. He was worried that he
might lose his home, that they might lose their home because of his
medical bills and he didn't know how he was going to pay them and, most
of all, he was too embarrassed to tell his children and ask them for
help. How many times have you heard a story like that?
It's personal for millions of families who have gone into bankruptcy
under the weight of rising health care costs, and so many, many, many--
a high percentage of the bankruptcy in our country--are caused by
medical bills that people cannot pay. It's personal for 45,000
Americans and families who have lost a loved one each year because they
didn't and couldn't get health insurance.
That is why we are proud and also humble today to act with the
support of millions of Americans who recognize the urgency of passing
health care reform and more than 350 organizations representing
Americans of every age, every background, every part of the country who
have endorsed this legislation. Our coalition ranges from AARP who said
that our legislation ``improves efforts to crack down on fraud and
waste in Medicare, strengthening the program for today's seniors and
future generations.'' I repeat: ``improves efforts to crack down on
fraud and waste in Medicare, strengthening the program for today's
seniors and future generations.''
To the American Medical Association, the Catholic Health Association,
the United Methodist Church and Voices for America's Children, from A
to Z, they are sending a clear message to Members of Congress, say
``yes'' to health care reform.
We have also reached this historic moment because of the
extraordinary leadership and hard work and dedication of all of the
Members of Congress, but I want to especially recognize our esteemed
Chairs, Mr. Waxman, Mr. Rangel, Mr. Levin, Mr. Miller, Mr. Spratt, Ms.
Slaughter, for bringing this bill to the floor today. Let us
acknowledge them.
I want to acknowledge the staff of the committees and of the
leadership. They have done a remarkable job, dazzling us with their
knowledge and their know-how.
I would like to thank on my own staff Amy Rosenbaum, Wendell Primus
and Arshi Siddiqui.
Now I will close by saying it wouldn't be possible to talk about
health care without acknowledging the great leadership of Senator
Edward Kennedy, who made health care his life's work. In a letter to
President Obama before he passed away--he left a letter to be read
after he died--Senator Kennedy wrote that access to health care was
``the great unfinished business of our society.'' That is, until today.
After more than a year of debate and, by the way, the legislation
that will go forth from here has over 200 Republican amendments, and
while it may not get Republican votes and be bipartisan in that
respect, it is bipartisan in having over 200 Republican amendments.
After a year of debate and hearing the calls of millions of
Americans, we have come to this historic moment. Today we have the
opportunity to complete the great unfinished business of our society
and pass health insurance reform for all Americans. That is a right and
not a privilege.
[[Page H1897]]
In that same letter to the President, Senator Kennedy wrote, What is
at stake? He said at stake are not just the details of policy, but the
character of our country. Americans will look back on this day as one
in which we honored the character of our country and honored our
commitment to our Nation's Founders for a commitment to life, liberty
and the pursuit of happiness.
As our colleague, John Lewis, has said, we may not have chosen the
time, but the time has chosen us. We have been given this country, an
opportunity to stay right up there with, again, Social Security,
Medicare, health care for all Americans.
I urge my colleagues to join together in passing health insurance
reform, making history and restoring the American Dream. I urge an
``aye'' vote.
{time} 2230
Announcement By the Speaker Pro Tempore
The SPEAKER pro tempore. The Chair will again remind all persons in
the gallery that they are here as guests of the House, and that any
manifestation of approval or disapproval of proceedings or other
audible conversation is in violation of the rules of the House.
Mr. AL GREEN of Texas. Mr. Speaker, I am proud to support H.R. 4872,
the Reconciliation Act of 2010 and the healthcare reform package that
its passage will complete.
Today, the House of Representatives has been given the opportunity to
take a concrete and powerful step toward completing the work of
reforming our healthcare system that began decades ago. For much of the
last year, my colleagues and I have debated many ways in which we could
work to lower costs, improve the quality of care and expand coverage.
What we pass today will begin to achieve all three.
In the wake of the financial crisis that has devastated our economy,
concerns of our nation's deficit are well-placed and wholly
appropriate. Despite what many of its opponents would argue, the
passage of this healthcare reform package will reduce the national
deficit by an estimated $1.3 trillion over the next 20 years according
to the Congressional Budget Office.
Through the course of this debate, we have seen misinformation about
healthcare reform instill fear into the hearts of the American people.
We have seen the distortion of truth breed uncertainty about whether
healthcare reform will be to the benefit of our country. Despite all of
the debate, and at times confusion, there remains one incontrovertible
truth: the cost of inaction, when our country spends nearly $2.5
trillion a year on healthcare, over 45 million Americans are without
health insurance, and 45,000 people die every year due to lack of
health insurance, is simply too great.
The time for debate has ended. The question we are faced with is
quite simple: do we act to shift the course of this country towards
affordable, quality healthcare, or do we continue down the path of
unsustainable costs and squander this historic opportunity to bring
about meaningful change in the lives of the American people?
I am proud to vote in favor of this giant step toward putting
Americans in control of their health care and I look forward to this
legislation being signed into law so that we may move forward with this
much needed reform.
Mr. SMITH of Texas. Mr. Speaker, Republicans and Democrats agree on
the need for health insurance to cover those who cannot afford it. But
this legislation is the wrong way.
The health care bill is built on the shifting sands of higher
premiums, increased taxes and reduced benefits. Such a foundation
cannot last and will be washed away by the American people in the
November election.
A majority of the American people want to choose their own health
care plan, not have the government do it for them. Under this bill,
many health care decisions will be made by federal employees, not
patients and their doctors. The result will be less care at higher
cost.
Mr. PUTNAM. Mr. Speaker, at the end of this term, I will have served
in Congress for 10 years. I have had the privilege of participating in
countless debates--from war resolutions and trade policies to the
aftermath of the 9/11 attacks--and working with Members of Congress on
both sides of the aisle on some of America's greatest challenges.
We now stand on the floor of the House of Representatives to address
one of today's greatest challenges in America--healthcare reform. While
this may be one of the more complicated issues we are faced with, the
goals--in my mind--are simple. We need to lower the cost of healthcare,
while expanding healthcare coverage to more individuals. To accomplish
this, I have advocated for policies like allowing small businesses to
pool together and form association health plans, providing incentives
for wellness programs and healthy life decisions, making reforms to our
medical malpractice laws, and allowing individuals to purchase
insurance across state lines. These policies are far-reaching, free-
market based, and--most of all--don't require new government
bureaucracies. Unfortunately, they all lost out to a partisan process
of backroom deals that have tainted this proposal and further
undermined the already low esteem in which the people we serve hold in
this institution.
Ever since the first 2,000 page healthcare bill was dropped on my
desk just prior to the vote in November, I have listened to
Floridians--from parents and patients to doctors and seniors--who
understand that healthcare is just too dynamic to be taken over by a
stale, cold federal government. They understand that we don't need to
model our healthcare system on those systems across the globe who envy
our quality of care, technology, and research investment. We don't need
some agency to make decisions about our family's healthcare that has
the efficiency of FEMA and the compassion of the drivers license
office. While we do have some aspects of our system that need to be
improved, Floridians understand we should address them in a manner that
actually solves the problem--not having government destroy the
innovation that comes from competition. Madam Speaker, they understand
this, but Congress clearly doesn't.
The misguided policies we are voting on today are sadly coupled with
the broken process they followed to get here. The measure we will vote
on hasn't seen a single legislative committee, bi-partisan negotiation,
or open process. Like anything with such an impact to the American
people, this legislation deserves the scrutiny of the legislative
process and the challenges that may come with amendments and committee
debate. In short, this measure deserves a public vetting to arrive at
the best possible outcome.
Had our founders seen the process this healthcare debate has taken,
they simply would not have recognized it as the House of
Representatives they envisioned. Would they have supported a process
that didn't even include the committees responsible for healthcare?
Would they have appreciated gimmicks that only budget analysts would
understand in order to ensure a certain overall cost? Could they
explain why a student loan bill was mysteriously attached to a massive
healthcare reform proposal or why Congress decided to give one state a
better deal than the rest of the country? Could they have ever imagined
a Congress that is only willing to dedicate two hours of debate to a
measure that spends $1 trillion?
Our schoolchildren are taught the way an idea becomes law and that as
an elected Representative, I have the ability to amend this legislation
on their behalf and spend days debating every provision that may have
been included. They know they deserve a process that allows their
representative to have a seat at the drafting table, not one where the
bill is dropped on his desk just prior to a vote. Even the most casual
observer of this process and this bill's journey would find it
unrecognizable from our most basic understanding of civics and
representative democracy.
When the outcome of this vote became more important than the product
itself, taxpayers lost. When the legislative process became an
afterthought to salvaging a presidency, taxpayers lost. When debate was
sacrificed for special deals, taxpayers lost.
Madam Speaker, this process is a disservice and has birthed a flawed
product that restrains patient freedom and choice, burdens future
generations with debt, undermines a competitive business model for
medicine and, most tragically, will reduce the most innovative
diagnostics and treatment on Earth to the lowest common bureaucratic
denominator.
Time and again, the government proves inefficient and obsolete in
changing times with rapidly emerging technologies. In medicine, that is
a recipe for obsolescence, archaic approaches, and delayed treatments
that costs lives and weakens the human condition.
While I do not hold up the current health care model as perfect--I do
observe the quality of the treatment options, the daily miracles made
possible by world-class technology guided by well-trained health care
professionals, and the range of options in large and small towns alike
as evidence that the American model is far superior to the cumbersome,
one-size-fits-all models that are found in nations like Canada and the
UK whose citizens frequently flee to our nation to find the quality
care they believe is not available in their own countries.
Tonight's vote against this bill is cast on behalf of patients and
doctors, taxpayers and citizens who value innovation, competition, and
the spirit of the individual that has created the American experience
and built this great nation into the envy of the world.
While we can and must do more to improve access and affordability, we
shouldn't sacrifice all we are as a nation for the security of mediocre
medicine, bureaucratically administered.
[[Page H1898]]
Mr. PAULSEN. Mr. Speaker, this body is nearing what will be a
defining vote for the future of our nation.
While Majority Leadership continued the arm twisting until enough
members would vote for the bill, the voice of the American people got
louder.
They have made it clear they do not want this bill. My constituents,
by a margin of over 3 to 1, have told me they don't like this plan--and
with good reason.
This bill will cost nearly 1 trillion dollars in the next decade
alone--and the true cost of this bill will surely go higher as
entitlement spending soars and other provisions are fully phased in.
The bill is loaded with job-killing tax increases--and an Associated
Press analysis said health care premiums will actually go up under this
plan.
The bill will also allow the IRS to verify if you have ``acceptable''
health care coverage and fine you if you don't!
This bill will cut $500 billion from Medicare and in turn use that
money for new entitlement spending. And history has shown entitlement
spending goes up, not down, over time. With our current entitlement
programs already headed for insolvency, why on earth would you
exacerbate the problem?
I would be remiss if I didn't mention that this legislation also
negatively impacts our Nation's veterans. It betrays the promise that
this county made to honor their sacrifice by failing to cover millions
of beneficiaries including dependents, widows, survivors and orphans.
The VFW has expressed their opposition to this bill and this body
should not pass any bill that negatively impacts our veterans. Those
families who have proudly served this country deserve better.
Finally, the legislation contains a $20-billion tax on American
medical manufacturers. This tax--which will hit manufacturers of
technologies now common in modern medicine such as pacemakers, stents
and MRI scanners--will be levied against many medical device
manufacturers in my home state of Minnesota. In the end, this will harm
jobs and cause patients to pay more for fewer medical technologies--the
exact opposite of what we need.
I believe this Nation needs real, bipartisan health care reform the
American people can support. This bill should be set aside and replaced
with common sense measures that will actually lower costs for everyone.
Ms. LINDA T. SANCHEZ of California. Mr. Speaker, whether all
Americans should have access to quality health care at a reasonable
price is a question a century old. First raised by Teddy Roosevelt in
1912, then repeated by FDR, Harry Truman, and later presidents, the
question almost answers itself. No nation can be strong whose citizens
are sick and poor. To improve our economy, to care for our people, to
fix our expensive and broken healthcare system, the time is now.
Truman argued that the principal reason why people could not receive
the care they needed in 1946 was that they could not afford to pay for
it. At the time, the cost of health care accounted for 4 percent of the
nation's income. Today, the reason people don't receive care most
likely remains its unaffordability, but the aggregate cost of health
care has since risen to 16 percent of the nation's income.
Having grown up in a working family of seven kids, I know how
important health insurance is. My parents couldn't predict which of us
might break a leg, need our tonsils out, or worse, but they could
predict that without insurance, they couldn't pay to get us the care we
needed. There is no reason that hard working Americans should be priced
out of needed healthcare.
Without doubt, this is not a perfect bill. It does not contain strong
employer responsibility provisions or a public plan to provide real
competition to private insurers. It cuts DSH payments for hospitals too
much. It benefits states that have left some of their poorest citizens
out of Medicaid without rewarding states like California that have been
doing the right thing all along.
It contains an Independent Payment Advisory Board, which would
severely limit Congressional oversight of the Medicare program and
place authority within the executive branch, without Congressional
oversight, judicial review, or state or community input. It also does
something no bill has ever done before--prohibits undocumented
immigrants from spending their own money to buy private health
insurance within an insurance exchange or marketplace.
But the bill's strength--that it makes health insurance accessible
and affordable for more than 30 million Americans who currently lack
insurance--is so much more important than its weaknesses.
After fifteen months of hearings, meetings, debates, and ideas, the
time has come for Congress to act to make healthcare better for all
Americans.
I take this vote after much thought and consideration, not for any
politician, but for my constituents who are anxious about whether they
will be able to afford care for themselves and their children when they
need it. For a nation as wealthy as America to have tens of millions of
people without health insurance is shameful.
Even those who have insurance fear losing their jobs, and with it
their insurance. Some are concerned that they will reach their annual
or lifetime caps on coverage. Others are anxious that their insurance
companies will simply drop them as soon as they get sick.
This bill, which my constituents have told me this Nation desperately
needs, will address a number of shortcomings in our current system.
In our current system, those who have insurance pay more to subsidize
care for those who don't have insurance. This bill changes that by
requiring everyone to have basic health coverage. Everyone has a stake
in improving public health. Currently, the uninsured don't get
preventive care, and once they're sick, they wind up in the most
expensive place to get treatment--the emergency room. The large number
of uninsured distorts our system, acting as a hidden tax on the
insured. This bill repeals that hidden tax.
In our current system, those with pre-existing conditions are
discriminated against. No child asks to be born with muscular
dystrophy, juvenile diabetes, asthma, or Down Syndrome. Yet current law
allows insurance companies to deny or limit their coverage. This bill
fixes that injustice, protecting our children, and ensuring they can
access coverage for life.
In our current system, some women pay twice as much as men for
insurance simply because they are women. This bill will change that so
insurance companies will treat all people equally.
In our current system, Americans who work just as long and just as
hard as their fellow citizens often lack insurance simply because they
work for a small company instead of a large one. This bill addresses
that too, by creating generous tax credits to small businesses to make
insurance more affordable, and by creating affordability credits to
help self-employed folks buy insurance at an affordable price in an
insurance marketplace.
In our current system, healthcare costs are skyrocketing out of
control. This bill will help rein in costs by paying doctors for
quality, not quantity, and actually reduces the budget deficit, making
our Nation more fiscally stable.
Oh, and one more thing, in our current system, millions of Americans
like their doctors and insurance companies. This bill allows you to
keep them. Millions of Americans will see no change in this bill except
for the added peace of mind that occurs when you are no longer at the
mercy of an insurance company that can drop or deny coverage at the
drop of a hat.
And I haven't even mentioned the improvements to Medicare: closing
the donut hole, eliminating co-payments on preventive tests, and
reducing fraud and waste to extend the life of the Medicare Trust Fund.
Yes, anyone who looks at this bill can find something wrong with it.
But I can't remember the last time I voted on a perfect bill here in
Congress. Just about every bill can be improved in one way or another.
On balance, this bill does what I came to Washington to do: to give a
voice to average working people, whose voices are too often drowned out
by the voices of moneyed interests.
Because I believe this bill would make America a stronger, more
stable, healthier, fairer, and more just Nation, I vote yes.
Mr. CONYERS. Mr. Speaker, I rise today in strong support of the
American people's call to pass health reform, and I urge this body to
pass this historic bill.
We are here at this moment, principally, because of one number: 45
million. These are the uninsured Americans, many of whom have lost
their job and their health insurance in the worst economic downturn
since the Great Depression. Today's vote on this imperfect legislation
is necessary because our fellow citizens desperately need access to
affordable comprehensive health care services. This legislation will
give them that foot in the door and pave the way for greater future
reforms.
America remains the only nation in the industrialized world where
health care is a for-profit corporate enterprise, where approximately
45,000 uninsured people die each year from lack of coverage, and over 1
million people go bankrupt each year.
Let me be clear. This is not a perfect bill. I would have preferred a
different approach that covered more people. But let me address those
who oppose this bill. Tomorrow, they are going to wake up and our
democracy will still stand. We will continue to live in the greatest
country with the hardest working, most patriotic, freedom-loving
citizens on the planet.
The real impact of the bill will be felt tomorrow when:
Insurance companies can no longer drop a person's coverage once they
become sick;
[[Page H1899]]
The average senior citizen will gain an additional $1,727 in
prescription drug coverage; and
Our children cannot be denied coverage based on pre-existing
conditions and will be covered under our policies until they are 26.
When health reform is fully enacted, approximately 31 million
additional Americans will have access to health insurance, with 15
million of them receiving care via an improved Medicaid.
Don't let anyone fool you--Medicare will be strengthened by this
bill. The only Medicare cuts in this bill are the billions in corporate
welfare subsidies to health insurance companies that provide minimal
benefit to seniors. The bill takes this wasteful spending and applies
these funds to benefit consumers, not insurance companies. Medicare
will become more affordable, offer more comprehensive benefits, and
continue to provide peace of mind to America's seniors for years to
come.
We will not end our efforts to improve our health system with the
passage of this bill. Just as we have improved Medicare and Social
Security, so too will we strengthen this initial package of reforms.
Members of the Senate Leadership have made it clear they will revisit
the idea of a public health insurance plan this year. I call on my
fellow progressives to hold firm in our insistence on such a vote. The
health insurance monopolies fear the competition an efficient not-for-
profit public health insurance plan would provide and that is exactly
why we must have an up or down vote on this proposal.
I support a public health option because I fundamentally believe in
the value of public health insurance. For this reason, I remain an
ardent supporter of universal single-payer health care. This system has
successfully provided quality, affordable, and cost-effective health
care wherever implemented, whether with Medicare, the U.S. military,
Europe, Taiwan, or Japan.
Adoption of a single-payer system is the only long-term means to
eliminate the
corporate-medical-industrial-complex which threatens to undermine our
health system with continued rising costs and an insatiable desire to
pass costs onto already burdened citizens. For-profit investor-owned
hospitals, prescription drug companies, and medical device
manufacturers are just as culpable as the health insurance industry and
future reforms must seek to address the profits-first mindset that
prevails in these industries.
If this bill passes, we should celebrate it. Tomorrow we will begin
the work to make it better--to truly secure health care as a human
right.
Mr. HOEKSTRA. Mr. Speaker, I rise today to vehemently object to the
government takeover of health care.
It is bad social policy, bad public policy and bad fiscal policy for
the United States.
The health care bills we will vote on today are estimated to cost
more than $1 trillion, will expand government bureaucracy, permit
taxpayer-funded abortions, increase taxes and cut Medicare.
Additionally, it includes egregious sweetheart deals such as the
``Cornhusker Kickback'' for Nebraska, ``Gator Aid'' for Florida and the
``Louisiana Purchase.''
My home state of Michigan alone will be forced to pay $710 million
annually for new Medicaid enrollees, money the state does not have to
spare. It is verging on denying the state's ability to regulate health
care programs and insurance and encroach on its sovereignty in doing
so.
Every American is personally impacted by health care. As such over
the last year Michigan residents and all Americans have voiced their
opposition with the health care proposals in Congress. It is
disheartening to see that Congress is blatantly ignoring the voice of
the public.
The U.S. health care system remains the best in the world, but still
needs reform. Reform can be achieved by targeted measures such as
allowing insurance competition across state lines and creating high-
risk pools of money for states to support those with pre-existing
conditions.
I had hoped that we could work in a bipartisan manner to achieve
reform of health care, but Republicans were not allowed a seat at the
table.
We do not need the federal government to take over one-sixth of the
American economy, and saddle states like Michigan with mandates, tax
increases and debt.
Mr. Speaker, in Michigan a situation has developed in which home
health car providers have been forced to pay union dues to state
because they accept federal dollars.
How can we be sure that the same will not happen to medical
practitioners who will be forced into a government-run system?
Additionally, I am concerned that the reconciliation bill that we
will vote upon today will completely federalize student lending,
leading to lost jobs, tax increases and the elimination of choice.
Mr. Speaker, I will be voting against the bills, and I respectfully
submit my remarks for the Record.
Mr. COBLE. Mr. Speaker, I rise in opposition to the proposed
government takeover of our health care system.
I have not come at this decision lightly. Although a small portion of
my constituents support this proposal, the vast majority want nothing
to do with it. Clearly there are areas of our health care system that
need to be improved. That being said, this bill is a complete overhaul
of the system.
Make no mistake about it. This bill will put the government in
control of our health care. It is a train wreck waiting to occur and
considering our current economic morass, we need no train wrecks.
It is with the best interests of all of my constituents, their
children and future generations that I will oppose this legislation.
Mr. POSEY. Mr. Speaker, I rise to express my strong objections to the
health care legislation, H.R. 3950, and the unprecedented, process
through which it is being considered. The overwhelming majority of
Americans are telling Washington through their letters, calls and every
poll that they don't want this bill. Nearly eight in ten of my
constituents who have contacted me on this issue have asked that I vote
against the bill.
Social Security is already unsustainable. Medicare is unsustainable.
Medicaid is unsustainable and reimbursements are already so low that
few doctors will even see Medicaid patients. These programs have tens
of trillions of dollars in unfunded liabilities. Rather than fix these
problems, the bill before us makes them worse. This bill takes over
$500 billion out of Medicare and spends it on this new health care
plan. It adds millions of new enrollees to Medicaid--already one of the
fastest growing federal and state budget line items. H.R. 3950 takes
over $53 billion out of the Social Security Trust Fund and spends it on
this new health care plan. And, they say that this bill will save the
taxpayers money.
The American people have figured it out and that is why they want
this particular piece of legislation stopped. It's not that they don't
want health care reform; it's just that they don't want this particular
bill. No one is suggesting that the status quo is acceptable. In fact,
I have cosponsored more than a dozen health care bills aimed at fixing
the problems with our current system. I suggested in a meeting with the
Secretary of Health and Human Services Kathleen Sebelius, that we move
forward with those things upon which we can reach agreement--like
addressing preexisting conditions and ending the practice of insurance
companies dropping coverage for someone when they get sick.
Unfortunately, she rejected that offer.
I want to talk just briefly about the cost of this bill. On Thursday,
a preliminary Congressional Budget Office, CBO, cost estimate of the
bill was released. But that budget included a number of gimmicks that
hide the real costs of health care reform legislation. I believe the
American people want and deserve honest budgeting because once the
smoke and mirrors are removed, they will have to pay the costs of this
bill.
Let's look at why we have the differences. It is important to
remember that the CBO can only estimate the costs of the specific
language that is presented to them. An analysis of the costs of the
bill that was released by the Senate Budget Committee found that after
you remove the budget gimmicks, this bill increases the budget deficit
by nearly $600 billion in the first 10 years and $1.6 trillion over the
second 10 years. This is a far cry from the preliminary budget estimate
from the CBO, which put the net effect of the bill at reducing the
deficit by $118 billion over 10 years. So, what causes this
discrepancy?
What are some of the reasons for the differences? CBO does not
include in its calculation the $53 billion that is borrowed from Social
Security to pay for H.R. 3950. CBO assumes these monies will not have
to be repaid to the Social Security Trust Fund.
Likewise, the bill includes over $500 billion in cuts to Medicare
program and assumes that future Congresses will allow these cuts to be
fully implemented. Anyone remotely familiar with Congress knows that
time and again Congress has stepped in to stop such Medicare cuts and
may well do so again in the future. Thus to assume that Medicare will
be cut by nearly $500 billion is simply not realistic. Furthermore,
rather than take these Medicare savings and spend them elsewhere, these
funds could have been used to help secure the long-term solvency of
Medicare.
This bill creates a new long-term care entitlement benefit, known as
the CLASS Act. This bill collects $70 billion more in premiums than it
will pay out in benefits over the first 10 years of the program. Rather
than keep this $70 billion in the Trust Fund to pay future benefits,
H.R. 3950 takes the money out of this trust fund and uses it to pay the
costs of H.R. 3950.
[[Page H1900]]
H.R. 3950 creates dozens of new programs; however, the CB0 cost
estimate does not include any costs associated with these programs. The
Senate Budget Committee estimates the 10-year costs of these programs
at $114 billion.
Medicare also faces more than a $200 billion shortfall in the amount
of funding needed to pay physicians. It would have been appropriate to
use the Medicare savings in H.R. 3950 to fix this problem. However,
H.R. 3950 leaves in place the 21 percent cut in payments to doctors.
Speaker Pelosi has said that we can expect another bill to come to the
House floor in a few weeks that fixes this shortfall. The cost of that
bill will simply be added to the deficit and no one will have to pay
for it.
So, rather than saving $118 billion over 10 years as CBO estimates,
the real costs will be hundreds of billions of dollars in deficit
spending in just the first 10 years. Between 2020 and 2029 the debt
rises even more.
Our nation has lost millions of jobs since January of 2008. To
restore these jobs, our nation would have to create 250,000 jobs per
month for each of the next 5 years. Hundreds of billions of dollars in
new taxes on small business and new costly mandates included in H.R.
3950 will only result in the loss of additional jobs and it will make
it harder for businesses to hire new employees. In fact, it is
estimated that this bill may result in the loss of more than 2 million
additional jobs.
Not only does this bill have a costly impact on businesses, but it
imposes tens of billions of dollars in unfunded mandates on the states.
Our state budgets are already stretched thin and governors and state
legislatures are cutting tens of billions of dollars just to balance
their budgets--something many states are required to do, but not
Washington. This bill makes that task harder for the states and will
ultimately result in higher taxes on individuals and businesses.
H.R. 3950 lacks sufficient protections to ensure that American
taxpayers are not forced to pay for the health care of millions of
illegal immigrants.
I am further concerned that this bill fails to include protections,
passed earlier this year in the House, that would ensure that taxpayer
money is not used to pay for elective abortions. This bill also lacks
sufficient conscience protections to ensure that health care providers,
doctors, nurses, hospitals, and health plans are not required to
participate or in any way support elective abortions.
Never before has Congress considered a bill that so fundamentally
changes the relationship between the people and the government.
This bill gives the federal government unprecedented powers. H.R.
3950 empowers government panels to make coverage determinations. It
also creates the Independent Medicare Advisory Board, IMAB, which is
given broad authority to make cuts in Medicare.
Over 4,000 times in this bill, the word ``shall'' appears, and
``shall'' indicates a federal mandate. In more than a dozen places, the
bill provides that there will be ``no administrative or judicial
review'' of a federal bureaucrat's decision.
It has been said that: ``A democracy cannot exist as a permanent form
of government . . . It can only exist until the voters discover they
can vote themselves largess from the public treasury. From that moment
on, the majority usually votes for the candidates promising them the
most benefits. Therefore the average age of the world's greatest
civilizations has been about 200 years. These nations have progressed
through this sequence: From bondage to spiritual faith; from spiritual
faith to great courage; from courage to liberty; from liberty to
abundance; from abundance to selfishness; from selfishness to apathy;
from apathy to dependence; from dependency back again into bondage.''
This bill vastly expands the powers of the Internal Revenue Service,
IRS. If this bill becomes law, the IRS may have to hire up to 16,500
additional employees just to enforce all the new taxes and penalties.
The bill empowers the IRS to: (1) verify that Americans have
government-approved health care coverage; (2) fine Americans up to
$2,085 or 2 percent of income (whichever 'is greater) for the failure
to purchase a government-approved plan; (3) confiscate tax refunds; and
(4) increase audits.
Finally, I would be remiss if I did not express my deep
disappointment with the process that has characterized this debate and
the manner in which this legislation has been written. I come from the
sunshine state, where we have very strict laws about transparency and
openness in government--a process that is seriously lacking in
Washington.
The House considered a bill in three committees last summer. A
handful of Republican amendments were adopted in those committees.
Unfortunately, when the bill was rewritten behind closed doors before
coming to the House floor in November; those amendments were removed
from the bill. When the House considered this bill in November 2009,
over 200 amendments were filed to be offered, but the leaders in the
majority allowed only one amendment to be voted on.
Likewise the Senate bill was written behind closed doors and no
amendments were allowed to be offered when it was considered in the
Senate in December 2009. It includes special earmarks meant to secure
the votes of particular Senators. Now we are debating that bill today,
and once again no amendments are allowed to be offered.
We are also debating a new bill drafted by the majority in the House
that purports to make changes to the Senate bill. Again, this bill was
drafted behind closed doors over the last few days and includes yet
again more special provisions intended to secure particular votes.
Yesterday, at the House Rules Committee, Republicans presented over 80
amendments that they wanted to offer to this bill, but not a single one
allowed an up or down vote.
Mr. Speaker, is it any wonder that the American people have so much
disdain for Washington and this body? This is a sad day characterized
by a lack of openness and transparency. The American people deserve
better.
Mr. KANJORSKI. Mr. Speaker, today I voted for legislation designed to
improve the affordability and accessibility of health care. Americans
already spend more on health care than the people of any other nation.
If we take no action, health care costs are expected to double over the
next 10 years, just as they have over the last 10 years. It is not the
bill I would have written if it were up to me alone, but it is the best
we can do at this time.
This was one of the most difficult votes I have ever cast, primarily
because there is a great deal of confusion about what this bill will
do. Over the last year, many people throughout Northeastern
Pennsylvania have taken the time to voice their thoughts on this health
care reform bill, and I have taken each voice into consideration. I
have heard the desperate pleas from people who have been sick and can
no longer obtain any insurance. I have heard from small business owners
who struggle to pay the premiums for their employees. I have also heard
from a sizable number of my constituents who fear they will lose
fundamental freedoms if this bill becomes law. From my careful review
of the legislation, I have come to the conclusion that this fear is
unfounded.
Democracy requires the consent of the governed, but that consent
needs to be informed with facts, not the widespread misinformation
which has permeated the national conversation about this legislation. I
had hoped that the House and Senate would conduct a conference
committee to iron out the differences between the House and Senate
bills televised by C-SPAN so that the American people would have an
opportunity to understand the provisions included in this very complex
bill. It is important to set the record straight between facts and
myths.
This bill does not empower the federal government to take over health
care. In fact, this bill preserves the employment-based private
insurance delivery system upon which a majority of working Americans
relies for insurance coverage. It allows participants to choose the
health insurance plan that best fits individual and family needs by
creating a marketplace of insurance plans, resembling the Federal
Employees Health Program used by all federal workers, including Members
of Congress. The bill attempts to rein in those private insurers by
prohibiting their most egregious abuses: denying coverage for
individuals with pre-existing medical conditions, imposing a lifetime
cap on medical care, and limiting the ability of individuals to change
jobs without the fear of losing insurance coverage. It will also enable
young adults to stay on their parents' insurance until age 26.
If people currently have health insurance, whether it is through an
employer or another means, their coverage will not change. If anything,
their premiums are expected to decrease because there will be more
people in the insurance pool. But, if people are unsatisfied with their
insurance, they will have the capabilities to switch to a plan that
best fits their needs.
Senior citizens have expressed a great deal of worry that they will
be denied services if this bill becomes law. In fact, seniors will
experience better coverage for their prescription drug costs and will
have no out of pocket costs for preventive care. In addition, this
legislation reduces excessive payments to private insurance companies
that administer Medicare Advantage Plans and applies those savings to
the bill. It also works to reduce waste, fraud, and abuse in the
Medicare program, which will help strengthen the program. As a result
of this legislation, the non-partisan Congressional Budget Office (CBO)
estimates that the solvency of the Medicare program will be extended by
more than 9 years.
This bill will help save American families money and prevent health
care costs from bankrupting our country. The U.S. spent 16 percent of
its gross domestic product, GDP,
[[Page H1901]]
on health care in 2008, more than any other industrialized country. CBO
estimates that number will rise to 25 percent without changes to
federal law. CBO also estimates that this bill will reduce the deficit
by $138 billion over the 2010-2019 period.
Many of my friends who oppose abortion have expressed concern that
their tax dollars could be used to pay for abortions. I have been
assured that this is not the case, and I am pleased that President
Obama intends to issue an executive order to clarify that no funds in
the bill will be used for abortion. Moreover, I will continue to remain
vigilant to ensure that the Hyde Amendment, which prevents federal
funding of abortion, remains the law of the land.
I was greatly disturbed when the student loan legislation was hastily
attached to the health care reform bill at the last minute because of
the impact it would have on the 1,100 Sallie Mae workers in my
district. Yesterday, Education Secretary Arne Duncan assured me that he
will use all of the tools at his disposal to help ensure that these
workers will remain employed.
I thank the many Northeastern Pennsylvanians who have shared their
thoughts with me on this important legislation over the past few
months. When you are sick, the last thing you should have to worry
about is how to pay the bills. Insurance is supposed to relieve this
worry, but instead the current system has made that worry worse. Today,
we are working to reverse this course.
Mr. GALLEGLY. Mr. Speaker, if Congress wants to remove fraud and
abuse from the healthcare system, it can start by overturning this
bill.
The Congressional Budget Office released an updated analysis of H.R.
4872. According to the Congressional Budget Office, this bill will cost
taxpayers $1 trillion. The analysis also confirmed that this bill will
raise healthcare premiums $2,100 more a year for millions of families
than if Speaker Pelosi had left healthcare alone.
It also reaffirmed that as many as 9 million people now enrolled in
employer-based plans will lose their coverage.
At a time when our military men and women are fighting terrorists
around the world, the national commander of the Veterans of Foreign
Wars urged Congress to vote the bill down because it does not protect
veteran healthcare plans.
At a time when unemployment has hit a record 11.6 percent in Ventura
County and 10.4 percent in Santa Barbara County, Speaker Pelosi's bill
adds $569.2 billion of additional taxes onto the backs of American
families and $52 billion on struggling employers.
It hurts seniors with $200 billion in cuts to Medicare Advantage and
raids Medicare and Social Security to fund the new mandate and hide the
true cost of the bill.
This bill must be overturned before the bulk of its provisions take
effect in 2014. I support real reform that reduces premiums, reduces
government spending and protects the doctor-patient relationship.
I cosponsored a bill that would provide real reform, but Speaker
Pelosi will not allow a vote on it. It includes:
Allowing small businesses to band together to purchase health
insurance for employees and use their combined bargaining power to
negotiate better health benefits at lower prices.
Reforming medical liability laws to discourage unnecessary and
frivolous lawsuits, which only drive up prices for everyone and force
doctors to practice defensive medicine.
Removing unnecessary regulations that prevent health insurance
companies from operating across state lines--which will provide the
competition without government-run health care.
Establishing high-risk pools to help people with pre-existing
conditions find affordable insurance.
I and many of my colleagues believe issues of portability, increasing
costs and rescinding coverage must be addressed. However, in doing so,
we must also protect a patient's right to choose the best coverage for
him or herself in a vibrant, competitive marketplace, not force
Americans into a one-size-fits-all government-run program designed by
Speaker Pelosi.
Mr. YOUNG of Florida. Mr. Speaker, four and a half months ago when
the House first considered health care reform legislation I voted
against it saying that it did not represent good public policy.
Nothing in the package of legislation we will consider today and
tonight changes my mind. It is still not good public policy, it was not
considered under an open process envisioned by the drafters of our
Constitution, and it will drive up--not down--the cost of health
insurance and medical care for individuals.
This bill cuts Medicare by $523.5 billion. This cannot do anything
but compromise the quality and availability of care for older Americans
who depend upon the program for their medical care. The Chief Actuary
for the Centers for Medicare and Medicaid Services confirmed that in
December when he advised Congress that ``providers for whom Medicare
constitutes a substantive portion of their business could find it
difficult to remain profitable and, absent legislative intervention,
might end their participation in the program (possibly jeopardizing
access to care for beneficiaries).''
A large percentage of my constituents in the 10th Congressional
District rely on Medicare for their health care coverage and a large
number of medical providers in my area care for a high percentage of
Medicare patients. In a survey I sent to every registered voter last
fall in my Congressional District, and to which more than 31,500
responded, 83 percent of the respondents said they were opposed to
paying for health care reform by cutting billions from the Medicare
program. They are concerned about the cuts in this legislation for
inpatient and outpatient hospital services, inpatient rehabilitation
services, long term care facilities, skilled nursing programs, hospice
services, kidney dialysis facilities, and medical laboratory services.
If this is not of concern enough to our nation's seniors, the
legislation we consider today cuts $200 billion from the Medicare
Advantage program, through which an estimated 47,000 residents of the
10th Congressional District receive their medical care. The Chief
Actuary for Medicare has said that cuts of this magnitude would force
more than 60 percent of these Medicare Advantage beneficiaries from the
program. Nationally, that totals 4.8 million Americans who would lose
their current coverage.
Despite the fact that this legislation makes draconian cuts in
Medicare, it will increase, not decrease, overall federal spending on
health care. The non-partisan Congressional Budget Office (CBO)
estimates that overall federal spending on health care will increase by
$390 billion over 10 years. This is at a time when proponents of this
legislation say it will save money.
Supporters of this legislation also tout the expansion in health
insurance coverage they claim it will bring about. However, this
expansion is due in large part to increasing the Medicaid rolls. In
fact, the CBO estimates that of the 32 million newly insured Americans
under this legislation, half, or 16 million, will receive their
insurance through the federally and state sponsored Medicaid program.
At the same time, millions of people will be enrolled in subsidized
plans on the government run health insurance exchanges and millions
will lose their employer sponsored health insurance.
Mr. Speaker, the majority of people I represent like the health care
coverage they currently have and do not believe this legislation will
improve the quality of their coverage. In my Town Hall by mail survey
last fall, 73 percent of those who responded said they are satisfied
with their current coverage and 70 percent say this legislation would
not improve the quality of their coverage. Furthermore, 75 percent say
Congress should not raise taxes to pay for this legislation and 74
percent say individuals should not be required to purchase health
insurance.
Many constituents have also expressed their grave concerns about the
insertion of the federal government into the precious patient-doctor
relationship. A perfect example of this is the creation of 159 new
boards, bureaucracies, and programs created in the 2,733 page health
care bill.
For example, in an effort to keep Medicare spending below targeted
levels the legislation creates the Independent Medicare Advisory Board.
This new entity will be required to submit recommendations to Congress
to keep Medicare spending below targeted levels. This could result in
additional coverage decisions being made by unelected bureaucrats
largely or exclusively on cost grounds.
Few issues have divided the American people as much as this health
care debate and given the interest and passion they have shown on this
matter demands that we give it serious consideration with a lot less
politics. Many of us have suggested that we start with legislation in
areas that we all agree we can fix now. That includes lowering health
insurance costs by allowing small businesses and individuals to pool
together in lower priced plans, requiring the coverage of individuals
with serious pre-existing medical conditions, prohibiting insurance
companies from canceling policies for those who become sick,
prohibiting insurance companies from imposing arbitrary spending caps
for policyholders, allowing families to purchase health insurance
policies across state lines, closing the Medicare Part D doughnut hole,
and providing for medical liability tort reform which the Congressional
Budget Office says would save $54 billion over 10 years in large part
due to lower medical malpractice premiums and the reduction of
defensive medicine practices.
In addition to Medicare cuts, the authors of this legislation pay for
new big government programs by raising federal taxes by $569 billion
over a ten year period. Many of those taxes will impact middle class
families. These are families who will pay a penalty if they choose not
to carry health insurance, the owners of small businesses who will pay
a penalty
[[Page H1902]]
if they do not provide health insurance for their employees, a sales
tax on medical devices, a tax on prescription drugs, and a tax on
health insurance premiums.
This bill also violates the President's promise that if you like your
insurance you can keep it. In addition to the 4.8 million seniors who
will lose their coverage under the Medicare Advantage program, the CBO
estimates that another 8 to 9 million people would lose their employer
based coverage when their employers choose to drop their coverage or
shift their coverage to the new subsidized policies on the health care
exchange.
This legislation would also contradict the President's promise that
the cost of health care coverage would go down. Instead, the CBO
estimates that the enactment of this legislation will raise private
health insurance premiums from 10 to 13 percent.
Mr. Speaker, most Presidents make it a practice of trying to bring
the country together in the face of difficult issues. We did this in
bipartisan fashion when it came to ensuring the financial solvency of
the Social Security system, reforming our nation's welfare programs,
and in engaging in an international war on terrorism. Yet this
administration has sought to do it their way whether the country agreed
or not.
Tonight we are faced with legislation that affects every American,
every American family, and every American business. The decision we
make tonight could be irreversible and the changes to the Senate passed
bill that are promised tonight may never take place. This is no way to
conduct our nation's business. It engenders no level of confidence in
the people who elected us to serve them.
Mrs. CAPPS. Mr. Speaker, I rise in strong support of passing
comprehensive health care reform legislation.
This moment has been a long time coming. I've worked on health care
since coming to Congress and passing comprehensive reform has always
been a major goal of mine.
I've met with and listened to my constituents, along with countless
doctors, nurses, hospital administrators, researchers, and other health
care experts. They know that America's health care system has many
wonderful aspects: it can provide the most cutting edge care, cure
diseases thought fatal only a few years ago, and devise new and
exciting drugs, devices and treatments with mind numbing speed.
But we also know our health care system's problems are legion.
Coverage is erratic, incomplete and can evaporate without notice; costs
are out of control for consumers, businesses and taxpayers; and health
outcomes are actually better in dozens of countries that spend far less
per capita than we do.
The legislation before us addresses these problems and will help
ensure that affordable, quality health care is always available to all
Americans.
The most trumpeted aspect of the bill is the coverage it would
provide to some 32 million Americans who are currently uninsured,
including an estimated 92,000 citizens in my own district. Passing this
legislation is a matter of life or death for them as an estimated
45,000 Americans die every year because they lack health care
insurance. In addition, the uninsured are much more likely to forego
primary care and delay other health care services leading to the
development of otherwise preventable disease, requiring much more
invasive and costly treatments.
The bill expands Medicaid to provide coverage for more very low
income individuals, and sets up state exchanges that will serve as
marketplaces for individuals and small businesses to buy affordable
health plans. The bill provides assistance to some individuals to
purchase coverage and tax credits to small businesses so that they can
provide health insurance to their employees. And it lets young adults
stay on their parents' plans until age 26. These new mechanisms and
support systems should provide coverage to the vast majority of today's
uninsured, improving both the physical and financial health of millions
of our fellow citizens.
But, perhaps just as important, the bill offers critical protection
for those already with health insurance. Today, insurance companies
often drop consumers if they get sick, refuse coverage for so-called
pre-existing conditions, and put annual and lifetime limits on a
consumer's coverage. This bill puts an end to those unfair practices. A
wife's diagnosis of cancer or a child's serious accident shouldn't be
the cause for a family losing health insurance just when it is needed
most.
Those currently with coverage will also benefit through lowered
insurance premiums. The Congressional Budget Office says premiums will
be 14 to 20 percent lower per policy holder. Furthermore, the
nonpartisan Robert Wood Johnson Foundation estimates that without
health care reform individuals and families would see their health
insurance premiums rise by as much as 79 percent over the next decade.
That is unaffordable, unsustainable and just one of the many reasons we
must enact this legislation.
The bill also makes significant investments to train our next
generation of doctors, nurses and allied-health professionals. This is
critical because today's current shortages of nurses and doctors would
only be exacerbated as we bring millions of new regular patients into
the system without the appropriate investment in our health care
workforce.
The legislation will also make it much easier to access preventive
health care services by eliminating co-pays for important recommended
screenings such as those for heart disease or cervical cancer.
Mr. Speaker, I've been hearing a lot from senior citizens concerned
about what our health care reform proposal would mean for them.
The bill will close Medicare's prescription drug ``donut hole,''
which in my Congressional district affects nearly 9,000 beneficiaries.
It is unfair that policyholders should have to pay insurance premiums
while receiving no coverage. The legislation before us today will give
seniors who fall into the donut hole a $250 rebate this year, 50
percent discounts on brand name drugs when they fall into the donut
hole beginning next year, and completely close the donut hole by 2020.
In addition to closing the donut hole, we take steps to crack down on
fraud, waste and abuse which will extend the solvency of the Medicare
Trust Fund by 9 years, according to CBO.
Finally, this bill is the largest deficit reduction measure in a
generation. According to CBO enactment of this legislation is projected
to reduce the federal deficit by $130 billion by 2020 and by over $1.2
trillion during the following decade. Earlier this year, the
Democratic-led Congress reinstated tough ``pay-go'' budget rules the
Republican-led Congress had allowed to lapse in 2003 and this health
care bill is a reflection of our determination to bring our federal
books back into balance as they were prior to the Bush Administration.
Mr. Speaker, I will not argue this is a perfect bill because it is
not. Most problematically, it lacks a public option, which would make
the insurance market more competitive, ensure the greatest possible
choice for consumers and bring down health care costs even more than
the bill does already. I am also deeply disappointed the bill contains
inappropriate language that may restrict a woman's access to
reproductive health services.
But I'm also not one to let the perfect be the enemy of the good and
in this case, we have legislation that is very good and deserves our
favorable consideration.
I urge my colleagues to do the same.
Mr. HOLT. Mr. Speaker, I rise today to support the health reform
package we are debating today. It is an important, very beneficial step
in America's history.
I see the need for this legislation when I meet with my constituents,
read their letters, and talk with them on the phone. A woman from
Pennington, New Jersey called me yesterday. She was concerned that she
would lose her job due to state budget cuts in New Jersey, which would
mean that she would lose her health coverage as well. She told me her
worries about finding affordable coverage while she looks for a new job
and tries to keep food on her table. To complicate her situation, she
has a pre-existing condition. This means that even if she could afford
health care, it is possible she could be denied due to her pre-existing
condition.
This woman's story is not unique. At a roundtable in Trenton, a
spouse of a cancer patient told me that when she and her husband came
home from the hospital after one extensive treatment, they returned to
foot-high stacks of insurance paperwork and $150,000 of out-of-pocket
charges for her husband's needed care. A self-employed woman from East
Brunswick wrote to me to let me know she pays $2,000 a month for her
family's coverage and still sometimes has to pay out-of-pocket to see
physicians.
I vote for health reform to help middle-class women and men just like
these hardworking New Jerseyans, who play by the rules and still find
health coverage out of reach.
Once reform goes into effect, families and small businesses will have
more control over their own health care.
Families with health insurance through their employers would benefit
from caps on yearly out-of-pocket costs. Seniors would find that
Medicare not only remains intact, but is improved--recipients would
receive free preventive care and better primary care. Small businesses
would have more health insurance options and additional support for
their health insurance expenses. Patients with diseases such as
diabetes or cancer would be able to obtain insurance without being
turned away because of their pre-existing condition.
The benefits of this health reform would be felt immediately upon
enactment of the health insurance reform package. For example, small
business owners who provide insurance for their employees would receive
tax credits, families would no longer face annual or lifetime caps on
their insurance benefits, and
[[Page H1903]]
seniors with high prescription drug costs would receive $250 of
additional assistance in their Medicare prescription drug plan.
The health reform package would do all these things while reducing
the deficit by $138 billion for the first ten years and by $1.2
trillion in the next ten years.
Today's vote is the culmination of over a century of debate about
health reform. Since Teddy Roosevelt ran for President in 1912, our
nation has been debating how to ensure that sick Americans can access
the care they need. This Congress has been debating this health reform
legislation in one of the most thorough processes in recent memory.
During the past few years, the House of Representatives has held 79
bipartisan hearings on health insurance reform, debated 239 amendments,
and heard from 181 witnesses.
The vote today brings this extensive process to a close at least here
in the house, finally passing health reform legislation that will
provide secure coverage to all Americans, ensure families have stable
costs, and improve Medicare for our seniors.
I urge my colleagues to vote in favor of this health reform package
to provide health security to our nation's families and small
businesses.
Mr. McCLINTOCK. Mr. Speaker, I rise in opposition to this flawed
health care bill. Under the provisions of this bill, Americans will be
required by federal law to purchase health insurance policies that
include every mandate imposed by the new federal health czar and will
face federal fines and even imprisonment if they refuse. And they will
pay for them through a combination of higher taxes, higher premiums or
lower wages.
The proposition that Congress has the power to order Americans to
purchase insurance--or any other product--is contrary to the
fundamental concept of individual liberty and antithetical to the
takings clause of the Fifth Amendment. If this precedent were to be
upheld, the federal government will have assumed authority over every
aspect of individual choice in the care of ourselves and our families
and can logically be extended to what foods we choose or to what
physical activities we engage in. Nor is this brave new doctrine
limited to health care. Once the precedent is established that
government may usurp individual decisions in the marketplace, what
limitation remains on its power to order any other of our decisions as
consumers?
Fortunately, the Constitution still protects our freedom from such
usurpations. It will fall to the Supreme Court to hold this act
accountable to the Constitution and it will fall to ``We the People''
to hold those responsible for it accountable at the polls.
Mr. HERGER. Mr. Speaker, the ``Reconciliation Act of 2010,'' written
behind closed doors and published just a few days ago, does nothing to
improve the Senate health care bill. It is simply more of the same:
higher taxes on investment and job creation, more cuts to Medicare to
pay for the new government health care program, and more special
backroom deals reflecting the Majority's determination to pass this
bill by any means necessary.
The reconciliation bill raises the Medicare payroll tax and, for the
first time in history, applies it to unearned income. This tax hike is
aimed squarely at small businesses and is sure to result in the loss of
even more jobs. Even worse, Congress is once again raiding the Medicare
and Social Security Trust Funds to pay for other programs.
The reconciliation bill also contains higher cuts to Medicare
Advantage--over $200 billion in all. If this passes, it is the end of
Medicare Advantage as we know it. Senior citizens in many parts of the
country will no longer be able to choose their Medicare plan. Once
again, these cuts have nothing to do with solving Medicare's long-term
budget problems. They are greasing the skids for the new government
health care program.
Not only does the reconciliation bill leave in place many of the
backroom deals included in the Senate bill, it adds several new ones,
including a special tax exemption for union multiemployer health plans
and extra Medicare money for hospitals and physicians in certain parts
of the country. The American people have repeatedly expressed outrage
at the special deals that are being made behind closed doors, yet the
Democratic Majority still refuses to listen.
One of the most serious concerns I have heard from my constituents is
that the Senate government health care bill will lead to rationing.
Unfortunately, the Rules Committee refused to make in order my
amendment to ensure that the new comparative effectiveness research
board established by the Senate bill cannot be used as a basis for
cost-based coverage denials. The Majority has repeatedly refused to
include an ironclad guarantee that Medicare will not start rationing
access to life-saving treatments because of their cost. The
reconciliation bill also leaves intact a new Independent Payment
Advisory Board of unelected bureaucrats that will have the power to
change Medicare payment policies without congressional approval, and
that cannot be repealed without a supermajority vote of the House and
Senate. This board is charged not only with issuing recommendations,
but also implementing Medicare policy. It is the ultimate embodiment of
government-run health care where decisions about access to innovative
new drugs, treatments and therapies are decided not by patients and
doctors and a functioning marketplace, but by unresponsive and
unaccountable bureaucrats working to contain costs.
In a final touch of irony for a Majority that has repeatedly insisted
that they are not aiming for a government takeover of health care, this
reconciliation bill incorporates a complete government takeover of the
private student loan industry. The Majority's rationale for this policy
is that the current policy of government subsidies for private
businesses is not controlling costs and has become too expensive. The
Congressional Budget Office has already told us that the Senate health
care bill will cause individual private insurance premiums to rise
faster than they would under current law. It is difficult to imagine
that a government-industry cartel will be any more efficient for health
insurance than it was for student loans. After a few years of this
policy, will Democrats again conclude that costs are out of control and
the government must take over?
The House should reject both the Senate government health care bill
and this reconciliation bill that only makes things worse.
Mr. FRANKS of Arizona. Mr. Speaker, today I resolutely intend to vote
against H.R. 3590 and H.R. 4872, the imposition of government-run
health care on the American people.
It appears that Democrats in this majority are determined to shove
this bill down the throats of the American people with not even a
single Republican vote. Never has such sweeping legislation--taking
over fully one-sixth of our economy--been done with a purely partisan
vote. Therefore, whatever ill comes from this bill, history should
record that Democrats alone chose the path of socialism over the
highway of freedom. Let future generations hold them accountable.
My first reason for voting against this bill will be the conviction
in my heart that I will be voting to protect my children, their
contemporaries, and generations to come from being forced to live under
the socialist ideal of a bill that will dim the light of freedom and
suppress many of the hopes they might have otherwise had.
I vote against this bill because it is my deepest conviction that its
cost will grow to threaten the entire economy of the United States in
the years to come. In every corner of the planet, in every corridor of
history, socialized medicine has always cost more, not less. Every
government health care program the United States has ever implemented
has cost many times the amount that was first predicted.
I am fundamentally convinced that the costs of this bill will so
overwhelmingly outpace present predictions that Congress will have no
choice but to drastically alter its provisions in the future.
I also intend to vote against this bill because of the provisions in
it that will increase the killing of unborn children in the name of
health care. Nothing so completely destroys the notion that this bill
is about compassion than the arrogant and cruel disenfranchisement of
those helpless unborn children who have no voice in this twisted and
corrupt process.
It is also my conviction that this bill will reduce the quality of
the greatest health care system in the world, and that many of those
who support it today will be its victims tomorrow.
Ultimately, this bill is about robbing America of one of its greatest
distinctives: freedom of the individual. It's about robbing the
American citizen of power, and putting it in the hands of left-wing
bureaucrats and elitists who think they know more about running
people's lives than the people themselves do.
Finally, I vote against this bill because I believe one day America
will look back and see what a tragic mistake that it was. It is my hope
that when that occurs, my children and my children's children will know
that it was my deepest desire to protect their freedom as faithfully as
my father protected mine.
Mrs. SCHMIDT. Mr. Speaker, I rise in opposition to both the Patient
Protection and Affordable Care and the Health Care and Education
Reconciliation Acts. Most likely, this package of bills will pass
tonight without a single Republican vote. It did not have to be this
way.
There is bipartisan consensus that our health care system is in need
of real reform. President Obama is correct when he says that the costs
associated with our current health care system are unsustainable. Too
many of my constituents are struggling to provide coverage for their
families and employees. The ever-rising costs of medical coverage have
left too many Americans without the means to purchase the health
insurance that many of us take for granted. Individuals with pre-
existing medical conditions are often unable to purchase insurance at
all. And, people should not
[[Page H1904]]
be forced to remain in a job they hate just for the health insurance
benefits.
We can begin to right these wrongs and others, as well. But, we do
not need to destroy a system that has given us the best doctors and
hospitals in the world and put us on the cutting edge of life-saving
technology and pharmaceuticals. Unfortunately, the package of bills we
are considering today, will actually increase premiums and ration care.
People will be forced out of their current coverage--whether they like
it or not. The bills will stifle economic growth and cost jobs. They
actually manage to cut Medicare by a half-trillion dollars, yet make
our entitlement crisis even more urgent. And, perhaps worst of all, it
allows federal funding for abortions for the first time in 34 years.
The President is fond of saying that Americans have been fighting for
this type of healthcare reform for a hundred years. That might be true
for some Americans. However, over the last nine months, we have all had
the opportunity to hear from the vast majority of Americans. We have
heard from them in a number of different ways--rallies at the Capitol,
letters, phone calls, and, yes, town hall meetings throughout all of
our districts. Their message is clear. If you were listening this
weekend, you would have heard it summed up at rallies at the Capitol--
``Kill the Bill.'' They fear government involvement in their medical
decisions. They fear a future of higher taxes and debt heaped on their
children and grandchildren. They fear a bill that rations care. And,
they are tired of the backroom deals and politics as usual. Worse than
all of these, they are afraid of a government too arrogant to listen to
what they have to say.
The House of Representatives is the people's house. We have a duty to
listen to what the American people are telling us. There is still time
to listen and defeat this flawed and dangerous bill.
Mr. MANZULLO. Mr. Speaker, the President's $1 trillion health care
bill is a job-killing disaster that will slap Americans with massive
tax increases and Medicare cuts immediately while delaying the bulk of
the health care benefits until 2014. This is not health care reform;
this is an unprecedented and unnecessary government takeover employing
some of the highest and cruelest tax increases and perhaps the broadest
expansion of the power of the federal government in history. It didn't
have to be this way. I do support health care reform. Bipartisan
alternatives exist that would make health care more affordable and
accessible for the uninsured without having to wait four years for
benefits.
Here are just a few of the most egregious policies within the
President's massive government takeover of health care. H.R. 3590 would
increase taxes on Americans by $569 billion, including a new $210
billion 2.9 percent ``Medicare'' tax on investment income; cut Medicare
benefits for seniors by $530 billion; increase Americans' health
insurance premiums $2,100 by 2014, according to the non-partisan
Congressional Budget Office; put another 3 to 5 million Americans on
the unemployment lines due to the heavy mandates that require employers
to provide health care coverage to their employees and families whether
they can afford it or not; require the Internal Revenue Service (IRS)
to hire up to 16,500 additional workers to enforce all the new tax
penalties on Americans who can not afford to purchase health insurance;
and puts another 16 million Americans on Medicaid, a struggling program
that pays such low reimbursement rates that 121 Walgreens stores in
Washington announced last week they would no longer accept Medicaid for
prescriptions. This bill will burden states with additional Medicaid
share costs. The State of Illinois, already facing a $12 billion budget
deficit with plans to cut $1.3 billion from local school funding, would
have to pay at least $1.8 billion in additional Medicaid sharing costs
to cover the additional enrollments. To add insult to injury, this bill
makes Americans wait until 2014 to receive the bulk of the benefits. In
fact, the ban on preexisting conditions does not kick in until 2014 for
adults.
This bill implements tax increases and Medicare cuts immediately, but
delays most of the benefit provisions for four years. However, when you
look at the first 10 years of benefits, the estimated true cost will be
$2.6 trillion. And that does not even include the nearly $1 trillion of
additional spending that was either pulled out of the bill to be dealt
with later or the result of correcting double counting cuts in
unrelated programs.
Plus, H.R. 3590 would not have a true firewall of protection to
prevent federal tax dollars from paying for abortions. According to a
Quinnipiac University survey released on December 22, 2009, 72 percent
of Americans said they oppose allowing abortions to be paid for with
public funds under any new health care system created by the
government. Thus, because a ``reconciliation'' bill cannot solve this
particular issue due to the fact that it is not directly a budget
issue, the President has promised to issue an executive order to ban
federal funding of abortion. However, an Executive Order cannot trump
the language in this bill that would become law, if passed. In 1952,
the Supreme Court struck down President Truman's executive order during
the Korean War that assumed federal control of certain domestic steel
mills due to labor unrest because it was an unconstitutional exercise
of lawmaking authority reserved to Congress. In 1996, the District of
Columbia Court of Appeals struck down an executive order issued by
President Clinton which authorized sanctions on federal contractors
that permanently replaced workers who went on strike because it
superseded existing law guaranteeing the right of employers the right
to hire permanent replacement workers. Finally, the Supreme Court
struck down an executive order issued by President G.W. Bush because
Congress, in enacting a statutory military commissions system, had
impliedly prohibited the President's invocation of military commission
jurisdiction over a terrorist detainee.
I also want to expand upon what I believe to be one of the cruelest
elements of this bill. As if raising taxes on struggling families and
their employers, cutting benefits for seniors, growing the IRS
enforcement police by thousands, and further jeopardizing the budgets
of all states in the union was not cruel enough, this bill creates a
new 2.9 percent tax on life-saving medical devices like the titanium
brace that was inserted into the spine of my wife after a cancerous
tumor shattered one of her vertebrae. That medical device saved my wife
from the wheelchair. The authors of this bill believe that life-saving
medical devices should be nearly three percent more expensive. I fail
to understand how we make health care more affordable by pursuing
policies that intentionally make health care more expensive.
As the former Chairman of the House Small Business Committee, I have
long supported legislation that would help small employers purchase
health insurance for their employees and their families. Of the 47
million uninsured Americans, 57 percent work for small employers who
cannot afford to offer them health insurance. I support two bipartisan
solutions that would go a long way to reduce the number of uninsured in
America. First, Congress should pass H.R. 2360, the Small Business
Health Options Program Act of 2009 (SHOP Act) as a stand-alone bill.
H.R. 2360 would allow small employers to purchase health insurance at
reduced group rates through national associations while still following
state rules. I am one of 60 bipartisan cosponsors of H.R. 2360, which
also enjoys support from the liberal Service Employees International
Union (SEIU), the AARP, and the conservative National Federation of
Independent Business (NFIB). A companion bill in the Senate was
authored by my fellow Illinoisan, Senator Dick Durbin, and enjoys
similar bipartisan support.
Second, Congress should also pass H.R. 1470, the Equity for Our
Nation's Self-Employed Act of 2009. This bill would let small employers
pay for their health insurance before they pay their Social Security
and Medicare tax liabilities, giving them the same deduction as large
employers. The self-employed pay on average $12,106 annually for family
health care coverage, and H.R. 1470 would save them $1,852 a year,
according to the Kaiser Foundation. I am one of 48 bipartisan co-
sponsors of H.R. 1470.
These bills would dramatically reduce the costs of health insurance
for small employers so they can better afford to provide coverage for
their employees and their families. And they will reduce the rolls of
the uninsured without increasing taxes, killing jobs, forcing Americans
into a government-run program, and burdening our children and
grandchildren with even more debt.
Mr. Speaker, I also support making the following four changes to
America's health care system. First, we need to reform our out-of-
control medical liability system. Medical malpractice insurance
continues to surge, skyrocketing health care costs and forcing doctors
and other medical professionals to practice ``defensive medicine,''
which entails ordering costly and often unnecessary tests to cover all
the bases from lawsuits. I am a cosponsor of the HEALTH Act (H.R. 1086)
that would fully compensate victims for medical injuries but place
reasonable caps on punitive and non-economic damages that often inflate
the awards and contribute to out-of-control liability and health care
costs.
Second, we need to expand tax-free availability to Health Savings
Accounts (HSAs). HSAs allow small business owners to offer more
affordable high-deductible health insurance plans to their employees
and make tax-deductible contributions to employee savings accounts to
allow their employees to build equity and assume personal control of
their health care needs. Congress should increase the tax deductibility
for these insurance plans.
Third, we need to preserve high-quality health care through America's
community health centers. I am a strong supporter of continued funding
of our community health center system, which provides high-quality
health
[[Page H1905]]
care to America's low-income families. The district I am privileged to
represent has one of the model community health centers in America, the
Crusader Clinic in Rockford, which serves more than 40,000 needy
patients in northern Illinois each year.
Finally, we need to create refundable tax credits to help low-income
Americans purchase health insurance. Low-income children are already
covered through the federal State Children's Health Insurance Program
(SCHIP), and I support refundable tax credits to help low-income adults
purchase health insurance.
Mr. Speaker, this bill today will increase taxes, cut Medicare, raise
health care premiums, and put millions more Americans on the
unemployment lines. And amazingly, most of the benefits--including the
ban on pre-existing conditions for adults--will not be available for
another four years. We should instead be pursuing the bipartisan
reforms that would make health care more affordable and accessible to
Americans now, and not make them wait four years for assistance. This
bill is certainly not the type of health care reform Americans deserve.
Ms. KILPATRICK of Michigan. Mr. Speaker, I rise today in support of
H.R. 4872, the Health Care and Education Affordability Reconciliation
Act. I urge all my colleagues to support this bill because it will
improve the accessibility and affordability of health care for millions
of Americans.
Today, there are more than 44 million Americans who lack health care
insurance. We must ensure that the needs of these Americans are met.
This bill will help us begin to do just that.
While we in Congress have deliberated and debated the costs,
challenges, and consequences of health care reform, millions of
Americans continue to sacrifice, struggle, and suffer. Hundreds of
people have sent me letters and e-mails, called and visited my office,
and participated in town hall meetings to express their opinions. The
majority of my constituents want and need health care reform. Many are
unemployed and struggling to maintain their health care insurance while
trying to make sure that there is food on the table, that they have
shelter, and that their lights, gas, and water are on. Others are
dealing with increases in health care premiums that continue to rise at
the will of insurance companies. Still others are trying to get
adequate treatment for serious illnesses and to pay for the medicines
that can help them.
I am a strong supporter of the single payer health care plan. I also
support a strong public option. I support this bill because it begins
the process of universal health care coverage for all Americans.
This measure expands coverage to 32 million more people, or more than
95% of Americans, while lowering health care costs over the long term.
It prevents insurance companies from discriminating based on pre-
existing conditions, health status, and gender. It creates health
insurance exchanges--competitive marketplaces where individuals and
small businesses can buy affordable health care coverage--and offers
premium tax credits and cost-sharing to low and middle income
Americans, providing families and small businesses with the largest tax
cut for health care in history. It also invests in Community Health
Centers to expand access to health care in communities where it is
needed most. The bill also empowers the Department of Health and Human
Services (HHS) and state insurance commissioners to conduct annual
reviews of new plans demanding unjustified, egregious premium
increases.
This bill puts patients and doctors in charge of their health care--
not health insurance companies. Children can no longer be discriminated
against because of preexisting conditions. Seniors will no longer have
to pay deductibles and co-pays. There will be free mandatory preventive
health care provided for all under all health care plans. Plus, there
will be a ban on lifetime coverage limits under this bill.
The bill cuts taxes to small businesses to help small employers pay
for health care coverage for their employees. Small businesses will
have tax credits and vouchers so as to be able to afford health care
coverage for their employees.
The bill makes key investments in Medicaid and children's health. It
expands eligibility for Medicaid to include all non-elderly Americans
with income below 133% of the Federal Poverty Level and provides fair
assistance to states to help cover the costs of these new Medicaid
populations. The measure also maintains current funding levels for the
Children's Health Insurance Program (CHIP) through fiscal year 2015 and
increases payments to primary care doctors in Medicaid.
The Health Care and Education Affordability Reconciliation Act
strengthens Medicare. It adds at least nine years to the solvency of
the Medicare Hospital Insurance Fund, fills the Medicare prescription
drug donut hole, improves Medicare payments for primary care, and
reduces overpayments to private Medicare Advantage plans. It
also provides new, free annual wellness visits; eliminates out-of-
pocket copayments for preventive benefits under Medicare, such as
cancer and diabetes screenings; and provides better chronic care, with
doctors collaborating to provide patient-centered care for the 80% of
older Americans who have at least one chronic medical condition, such
as high blood pressure or diabetes. The bill also encourages
reimbursing health care providers on the basis of volume instead of
value by including a number of proposals aimed at moving away from the
``a la carte'' Medicare fee-for-service system toward paying for
quality and value, while reducing costs for America's seniors.
This legislation reins in the abuse by health insurance companies of
arbitrarily increasing premiums and stops insurance companies from
dropping individuals from policies when people get sick and need health
care insurance. If you change or lose your job, you will still have
health care coverage. When you enter a hospital, you and your family
can rest assured, knowing that your policy will cover the costs
associated with your health care.
Last, this legislation demonstrates fiscal sensibility and
responsibility. It will reduce the deficit by $138 billion over the
next decade, with an additional $1.2 trillion in additional deficit
reduction in the following decade. The bill tightens current health tax
incentives, collects industry fees, institutes modest excise taxes, and
slightly increases the Medicare Hospital Insurance tax for individuals
who earn more than $200,000 and couples who earn more than $250,000. It
includes a fee on insurance companies that sell high cost health
insurance plans to promote smarter, more cost-effective health coverage
choices and changes health care tax incentives by increasing penalties
on nonqualified distributions from health savings accounts, capping
federal saving account contributions, and standardizing the definition
of qualified medical expenses. The cost of health care reform under
this legislation is fully paid for, in large part, by eliminating
waste, fraud, abuse, and excessive profits for private insurers.
As Democrats promised the American people, this bill is fully paid
for. This legislation is the single largest deficit reduction tool in
the history of our country. It is not balanced on the backs of our
children and our grandchildren.
My family and my faith provide the foundation for my commitment to
service. I am honored and humbled to represent the people of the 13th
Congressional District. As Members of Congress, we serve others.
Through this service, we often provide people with the tools and
resources they want and need. Our service not only changes us for the
better by giving our lives meaning and fulfillment, but it also creates
positive change in the lives of others. Like a raindrop in a river, our
service creates ripples that leave an indelible impact on all those it
touches.
Today, we will make history by finishing what many Congresses before
us started. The debate has gone on long enough. The American people
want action. We must reject the status quo. We must stand up and do
what is right. We must be a voice for the voiceless, give hope to the
hopeless, and provide help to the helpless by supporting health care
reform now.
Let us be the light in the darkness by voting in support of the
Health Care and Education Affordability Reconciliation Act. It will
give much needed assistance to millions of Americans by making health
care affordable for the middle class, providing security for our
seniors, and guaranteeing access to health insurance for the uninsured.
It is common sense for the common good, and I urge all my colleagues to
vote yes on this historic measure.
Mr. LARSON of Connecticut. Mr. Speaker, I rise on this momentous day
in support of this historic legislation. Just as our predecessors stood
up for the American people to pass Social Security and Medicare, today
we affirm our commitment to families across this country by passing
comprehensive health care reform. Today, Democrats are once again
showing whose side they are on, the side of the American people.
While my colleagues on the other side of the aisle like to focus on
those who are against this effort, I've heard from too many of my own
constituents whose stories exemplify why we need health reform and
encouraged me to support this bill.
Constituents like Jody from Bristol. Jody and her family had to
downgrade their health insurance after their premiums jumped 30% in one
year. Just a few months later Jody was diagnosed with Crohn's disease.
After 12 months her medical debt was more than $30,000. Now, even after
she has insurance, she is struggling to pay off the $35,000 in credit
card bills her family amassed to pay her health care.
It's in stories like these, of people facing severe financial
difficulty because of medical debt, being denied coverage because of a
pre-existing condition, or losing their coverage when they get sick
that creates the moral imperative to right these wrongs. In this bill
we
[[Page H1906]]
will cap out of pocket costs, end discrimination based on pre-existing
health conditions, and end the practice of insurance rescissions.
The American people may not like the complicated legal language of
the bill or the messy process it takes in Washington to get historic
acts accomplished. But after this bill is signed the parent whose
children have been denied coverage because of a pre-existing condition
will be able to get health insurance for them; young adults will no
longer have to fear being without coverage because they will be able to
stay on their parent's insurance; seniors will get relief from
skyrocketing prescription drug prices; and small businesses will get
tax breaks for offering their employees health.
Once this bill is signed, this country will be stronger, the economy
will be stronger and the American people will be stronger than ever
before. I thank the Speaker and my Democratic colleagues for their
efforts on behalf of the American people and urge my colleagues to
support this legislation.
Mr. GARAMENDI. Mr. Speaker, today, Democrats in the House of
Representatives voted to form a more perfect union. By expanding health
care coverage to 32 million Americans, we are continuing the proud
American tradition of promoting justice, ensuring the general welfare,
and broadening access to life, liberty, and the pursuit of happiness.
Republican leaders in the 1930s said Social Security would lead to
``the lash of the dictator'' and in the 1960s said Medicare would lead
to grandparents telling stories of ``what it once was like in America
when men were free.'' Yet with time, Social Security and Medicare
became incredibly popular services cherished by most Americans. A
broader consensus emerged, and a more perfect union was formed. I am
confident that the same will soon be said about today's health care
reform bill.
When the people get past the slogans, the fear tactics, and the gross
distortions, what they find in this legislation is a series of ideas
widely popular and aligned with the best of American values. This is
the second largest deficit reduction bill in 20 years. In my district,
9,000 people with preexisting conditions will finally be able to have
access to insurance. 96,000 seniors will see their Medicare improved
with significant prescription drug discounts and free preventative
screenings. 106,000 families will receive tax credits to make their
coverage more affordable. 52,000 young adults will be able to attain
coverage through their parents' insurance. 13,100 small business owners
will receive significant tax rebates. 1,400 families will avoid
bankruptcy. A similar story exists in every corner of this great
country.
In the fight to extend health coverage to every man, woman, and
child, this bill is an incredibly important beginning. But it's still
just a beginning. ``A more perfect union'' implies that the progress of
the American experience is never complete. Each subsequent generation
is expected to pick up the torch and continue on our long road toward
positive change. Today the House of Representatives bestowed upon this
great nation the most historic health reform since Medicare. I am proud
to have voted ``yes'' for health care reform. I won't live to see a
perfect union, but it is a tremendous honor to see a more perfect union
formed before my eyes.
Mr. OBERSTAR. Mr. Speaker, today the House of Representatives crosses
a historic threshold in the evolution of social justice, quality of
life, equity of health service delivery, and a worthy legacy for our
children, with passage of comprehensive health care reform legislation.
Our Nation enjoys the best, but the most expensive health care in the
world. The comprehensive health care legislation under consideration
will preserve what works best in our health care system and make that
system more efficient and affordable.
In Minnesota and throughout the Nation, citizens will quickly see the
benefits of this legislation that includes important consumer
protections to reduce the power of health insurance companies. You will
have greater control of your health care decisions. This bill will
assure that no one's current health care can be dropped. No one will be
forced out of the health care they now hold. No one will be denied
coverage because of a previously existing condition. No one's health
insurance will be dropped because of lifetime caps; no one can be
denied when they need their health insurance the most. People will be
able to retain their health insurance if they change jobs.
For seniors, the legislation closes the doughnut hole that has
existed for five years, which will save seniors thousands of dollars in
prescription drug costs. Young adults will be able to stay on their
parents' policy until age 26.
If we fail to provide health care for all of our citizens, we all
will pay higher taxes and higher health insurance premiums because we
eventually pay for ``sick care'' rather than make the wise investments
in the promotion of preventive health care.
This health care legislation, which assures that all Americans will
be able to have and to keep health insurance, is central to our
economic recovery and to balancing our federal budget.
To be sure, this health care reform legislation will not cure every
shortcoming in our health care system, but unquestionably the status
quo is unacceptable and unaffordable. For far too long, too many
citizens have been denied essential health care, and our commitment to
fundamental justice demands that we make affordable access available to
every American.
This health care legislation will provide numerous benefits for
Minnesota and the Nation. Importantly, this legislation expands access
to health care to more than 32 million Americans. This expansion of
health care will be achieved without increasing the federal deficit.
The nonpartisan Congressional Budget Office has objectively analyzed
the legislation and has determined that its enactment will reduce the
deficit by $143 billion over the first decade and more than $1.2
trillion over the second decade. The health care legislation is fully
financed by ending the excessive subsides in the Medicare Advantage
program and by additional changes in Medicare reimbursement that will
make Medicare more efficient without reducing essential Medicare
benefits; it will expand the solvency of the Medicare Trust Fund by an
additional seven years.
This health care legislation also includes important improvements in
rural health care for Minnesota and the Nation. I was concerned that
the original House health care bill did not incorporate a number of
necessary reforms to expand access in rural America. I am pleased to
report that the health care legislation under consideration not only
expands health insurance coverage in rural America, but it also
promotes the training and placement of health care professionals in
rural areas. I am also very pleased that this legislation addresses the
longstanding geographic disparity in Medicare reimbursement. Northland
health care providers have been greatly disadvantaged by unfair
Medicare reimbursement, and this legislation closes that gap and moves
us inexorably toward payment parity with the rest of the country.
Just as the Hippocratic oath requires that medical providers adhere
to the admonition of ``First, do no harm,'' the same is true for
legislators, and this legislation, while not perfect, will implement
significant and positive changes in the delivery of health care.
This is especially true with regard to vulnerable women and unborn
children. I am confident that abortion will not be funded in this
legislation. Current law dating back to October 12, 1979 (Public Law
96-86), has contained a federal prohibition on the use of federal funds
for abortion in community health centers. Conscience clause protections
that have existed in the past, that are in effect today, will remain in
effect in the future. The legislation also prohibits the use of federal
tax credits and cost-sharing assistance to pay for abortion. I am very
pleased that President Obama has prepared and will issue an Executive
Order upon enactment to reaffirm the enforcement of current law that
prevents the use of federal funds for abortion.
Today, we keep faith with the American people. Today we ensure that
quality, affordable health care is available to everyone to this
generation and generations to come.
Support this bill.
Mr. TOWNS. Mr. Speaker, I would like to clarify several points in
Section 1334 of H.R. 3590, regarding the Office of Personnel
Management's authority to provide oversight and set premiums of multi-
State plans.
OPM, of course, has administered the Federal Employees Health
Benefits Program for over 50 years, and that program has served as a
model for the Exchanges envisioned under this legislation. In
administering the FEHB Program, OPM has been able to address the
problem of uniformity of benefits and requirements across State lines
using its authority under 8902(m) of Title 5. Section 1334(a)(4) of the
Senate-passed bill states that ``the Director shall implement this
subsection in a manner similar to the manner in which the Director
implements the . . . Federal employees health benefit program under
chapter 89 of title 5, United States Code''. The intent of this
provision is that OPM oversee multi-State health plans in the same
manner in which oversight is provided under the FEHB Program for the
purposes of uniformity of health insurance plans. OPM should exercise
this authority, as it does in the FEHBP, to ensure that multi-State
plans offer uniform benefits, negotiate premiums with multi-State
plans, and require these plans to set aside a certain amount of reserve
funds. Moreover, it is imperative that OPM issue rules and guidelines
as necessary to effectively and efficiently administer the multi-State
plans, including for uniform adjudication procedures for disputes
involving the multi-state plans.
Another issue that requires clarification is the interaction between
the Secretary of Health and Human Services and the Director
[[Page H1907]]
of OPM. The legislation gives the Secretary broad authority to issue
regulations governing the operation of State Exchanges. Any rule or
regulation governing plans offered on State Exchanges would affect
OPM's administration of the multi-State plans, which will also be
offered on the Exchanges. There are overlapping responsibilities
between HHS and OPM with regard to the multi-State plans offered on
State Exchanges. The legislation envisions that the Secretary of HHS
will coordinate and consult with the Director of OPM on any policy
decisions that would affect the administration of multi-State plans.
This joint effort is essential to ensuring the proper operation of the
multi-State program as envisioned by Section 1334.
Under section 1334, OPM is directed to ensure that sufficient
resources are allocated to the ongoing administration of the FEHBP. The
intent of this provision is to ensure that essential resources are not
pulled away from FEHBP in order to start up the new program created by
this bill. However, where greater efficiencies can be found from the
administration of both programs jointly, we would expect OPM to adopt
that approach.
Lastly, section 2714 of H.R. 3590 would allow unmarried adult
children to remain on their parent's plan up to the age of 26. Congress
intends that this mandate apply to individual FEHB plans in their
capacity as private health insurers and to the FEHBP as a group health
plan. This Congressional Budget Office incorporated this interpretation
of section 2714 in preparing its cost estimate of the legislation.
Given the economic conditions in country, this is an important reform
that will help families across the country, including the families of
federal employees and retirees. I am pleased to support this provision
as one of many reforms that will improve health care coverage for low
and middle income Americans.
Mr. BOUCHER. Mr. Speaker, health care reform is needed. More than 36
million American citizens do not have health insurance, and millions
more are underinsured and cannot afford to pay for the medical care
they need. Those who have health insurance are finding that health care
costs and health insurance premiums are rapidly rising. In fact, health
insurance premiums are increasing 3.5 times faster than the rate of
increase in family incomes.
This status quo is unsustainable, and finding a way for everyone to
afford health insurance is necessary to benefit both the uninsured and
those who have insurance. It is also essential that health insurance
reform control health care costs and prevent rapid increases in health
insurance premiums. But reform legislation must also ensure that the
residents of my district in Southwest Virginia continue to have access
to the high quality health care services that are now delivered
locally.
After reading and carefully reviewing the legislation, I oppose
passage of the health care measure before the House today. My concern
largely centers on the dramatic reductions in Medicare funding required
by the legislation. Over the next 10 years, the bill requires that
Medicare funding be reduced by $450 billion. In fact, in April of this
year, doctors in our region and across the nation will have their
Medicare payments reduced by 21 percent. Over the next several years,
additional reductions in payments to doctors will occur. Other health
care providers will also experience substantial reductions in their
Medicare reimbursements. These Medicare payment reductions are fully
accommodated by and expected to occur in order to achieve the $450
billion Medicare payment reduction required by the reform legislation.
The population of the Ninth Congressional District is more elderly
than in the typical congressional district. Most senior citizens in our
region depend upon Medicare to pay their medical bills. Therefore,
these Medicare funding cuts will be far more harmful to the population
of our region than to the population of the typical congressional
district. The dramatic cuts in Medicare funding that would be required
by the health reform bill would adversely affect the quality of health
care for senior citizens and other Medicare recipients.
Because Medicare is paying less, doctors, hospitals and other health
care providers would increase charges to patients who have health
insurance to make up for what they are not receiving from Medicare.
This cost shifting of some substantial portion of the Medicare cuts
would raise health insurance premiums for those who have insurance.
While it is important that means be found to enable everyone,
including those who are currently uninsured, to be able to afford
health insurance, achieving that goal cannot occur at the expense of
people who are currently insured. Having concluded that these dramatic
Medicare cuts would both decrease the quality of health care that is
delivered to our region's senior citizens and result in increases in
health insurance premiums for the currently insured, I simply cannot
lend my support to passage of the bill.
I am also concerned about the unsavory deal-making that occurred in
the United States Senate when the health care bill was considered in
December. Some states received special benefits at the expense of other
states. While the measure before the House today removes several of the
special benefits, others remain and were not removed by the
legislation. For example, the states of Louisiana, Tennessee,
Connecticut and Montana have each received special benefits in the
health care reform legislation not made available to other states. I
simply cannot countenance this kind of deal-making which goes well
beyond the bounds of normal legislative negotiations.
In my view, the legislation does not do enough to eliminate the
historical disparity in Medicare funding between urban areas and rural
areas under which rural areas receive less than the urban regions of
the country. There is no justification for Medicare paying less for
medical procedures performed in our region than in the cities.
The bill also fails to achieve the tort reform which is necessary to
control health care costs. Virginia's tort reform law, which was
adopted when I was a member of the Virginia General Assembly, has
worked well, and I have urged that it be a model for national
application. Unfortunately, the reform bill fails to include this
needed provision.
I deeply regret that the legislation does not have a bipartisan
foundation. On a matter of this scope, affecting every American
citizen, the best ideas of both political parties should be drawn upon
in crafting balanced legislation that well serves the public interest.
That did not happen as the reform bill was constructed.
Reform is needed, but the measure being debated in the House today
falls short. Because of massive funding reductions for Medicare, it
would adversely affect the quality of care received by Southwest
Virginia senior citizens. It would result in health insurance premium
increases for those who have insurance. It contains unacceptable
special benefits for some states at the expense of the others. It does
not correct the unwarranted disparities in Medicare reimbursements that
penalize rural areas. It does not contain meaningful tort reform, and
it lacks the necessary bipartisan foundation.
The reform legislation contains many helpful provisions; however, in
my view its shortcomings outweigh its merits. I will cast my vote
accordingly.
Mr. PRICE of North Carolina. Mr. Speaker, ``once to every man and
nation,'' wrote the great abolitionist poet James Russell Lowell,
``comes the moment to decide.''
Mr. Speaker, there are moments in history when it becomes clear that
we simply cannot wait any longer to do what is right. When we have the
opportunity to take a significant step to make our country better, the
sort of opportunity that comes only a few times in a lifetime. We face
such a moment tonight.
Our health insurance system is falling far short of the American
peoples' basic needs. It isn't working for families, who have seen
their insurance premiums increase 75 percent over the past decade,
while their earnings have risen only 14 percent. It isn't working for
young adults, whose parents' policies stop covering them in their early
twenties in most states, as if people that age don't need health
insurance. It isn't working for people who have pre-existing conditions
and can't find affordable coverage. It isn't working for the countless
Americans whose coverage has been revoked when they get sick and need
it most. And it isn't working for small business owners who want to
provide coverage for their employees but can't access the low group
rates that insurance companies willingly negotiate with large
employers.
Over the past year, I have attended numerous town hall meetings and
roundtable discussions. I have met personally with doctors and
patients, parents and children, seniors and students, business owners
and employees. I have read thousands of letters and emails from
constituents about this critical issue.
In the course of these conversations, I have heard a rich and diverse
range of views on the current state of our nation's health care system,
but one conclusion has been shared by almost everyone: The status quo
is unacceptable.
Our current system penalizes the sick. It sells young people short.
It puts small businesses--the primary engine of job creation in our
country--at a competitive disadvantage. And instead of medicine, it
offers seniors the Medicare doughnut hole.
Why, then, would we continue to accept it? Particularly when we have
before us a carefully crafted bill that directly addresses the system's
flaws, preserves its strengths, and sets us on the path to meeting
longer-term challenges.
The time for reform is now.
In an effort to defeat this bill, some of my colleagues have
fabricated claims about ``death panels'' and damage to Medicare. They
have raised the specter of ``socialism'' and ``government takeovers''
when they know quite well that this bill leaves the provision of
[[Page H1908]]
care, and most insurance, in the private sector. They urge us to
``start over,'' but when challenged to come up with an alternative,
they produced a plan that leaves insurance discrimination in place as
well as tens of millions of uninsured.
Reform will save money for employees, business owners, and taxpayers.
It will end insurance company abuses. It will let young people stay on
their parents' policies until age 27. It will extend coverage to 95
percent of Americans. It expands community health centers and increases
the number of primary care doctors and nurses. And it will end the
hidden tax that the insured pay every month in the form of higher
premiums.
If my colleagues don't want to take my word for it, ask some of the
people--right in their own backyards--who have lived through it
firsthand. Ask David Swanson, whose insurance company raised the
premium for his daughter's coverage 54 percent when she turned 17. Ask
Blake Anderson, a small business owner who cannot afford coverage for
his four employees. Ask Libbie Hough, who fears her 18-year-old
daughter won't be able to find insurance when she finishes college
because of a genetic disorder. Or ask the thousands of Americans who
think they have good coverage until they get sick and hit annual or
lifetime benefit caps, or lose their jobs.
Mr. Speaker, the American people have waited long enough. We face an
historic decision tonight, one that will resonate throughout our
country, as have Social Security and Medicare, for decades to come. Let
us seize the moment for the people we were elected to serve, and for
future generations.
Mr. RAHALL. Mr. Speaker, throughout my career of public service,
there have been a few critical challenges that have remained at the top
of my priority list; protecting our coal miners and our coal jobs and
the need to provide our people with access to affordable, quality
health care.
Across southern West Virginia, especially in rural areas where senior
populations are high, that challenge has been particularly daunting,
because so many health insurance companies have been increasingly
putting high profit margins above all else, even the compassionate
treatment of the sick and the elderly.
I have consistently spoken out against the abuses of and mistreatment
by huge, for-profit health insurance companies. And I have advocated
for competition, recognizing that it is good for consumers and drives
down prices for all buyers, while driving up quality of service.
At the same time, I have consistently stood against the use of
federal funds to pay for abortions--a stand I took again when I worked
to have anti-abortion language included in the original House-passed
health care bill. That was, in fact, one of many issues that I heard a
lot about from West Virginians in recent months and that I successfully
pressed to have addressed in the House bill.
With the Executive Order strengthening the life protections in this
bill, we have achieved a firm anchor for the protection of life in this
country, reflecting the principles of the Hyde Amendment, no federal
funding for abortions. Administrative chipping away and mischief will
be held at bay with this order throughout this administration. Future
administrations should be held to this standard.
Health care is a deeply personal issue for all Americans. But it is
also true that there are no people in the world more personally
generous than Americans when it comes to helping the ill and the
injured.
I understand people's frustrations and concerns over coal, jobs, our
economy. The rhetoric about health care this year has been emotional,
at times angry, and, ultimately divisive. Much of the legitimate debate
has been undermined by millions of dollars in advertising, underwritten
by massive health insurance companies interested only in protecting
their record profits and lucrative salaries. The result has been a
polarized public and a polarized Congress.
But underlying the most contentious, most calculatingly advertised
issues, there can be found common ground. Certainly the status quo--
where honest, hardworking parents are forced into bankruptcy to afford
lifesaving treatments for their child and where longtime, loyal workers
lose their health care coverage along with their jobs during tough
economic times--does not comport with American values.
One of my constituents, Fred Long, is a Vietnam veteran and a proud
West Virginian who has long had private health insurance. Fred, blessed
with good health, needed his insurance little until he was 63 years old
when he had to have cataracts removed from both eyes.
Fred's brother was born with cerebral palsy. His problems were
covered by SSI and Medicaid. He, too, had cataracts removed, but
because of Medicaid, it did not cost his family a dime.
The two brothers had the same procedure, used the same hospital, and
same doctor, yet Fred's surgery cost him $3,099.36 despite Fred's $480
a month health insurance premiums.
Mr. Long closed his letter to me with this:
``. . . how many thousands of dollars have been paid in insurance
premiums over the years . . . I don't know if this will be of any help
in changing the thinking of those that can't see where national health
care would benefit the working man.
``The insurance companies could have done this, collected from those
that weren't sick and paid the heath care cost for those that were
sick, just like the government helped my brother when he needed it. He
is on Medicare now and I just hope I can get by the next few years when
I can sign up for Medicare. (Sincerely, Fred Long)''
Mr. Long's personal story echoes so many others I have heard from all
across southern West Virginia--this is just one of the reasons I
believe health care reform is necessary.
We must end the polarization of America and find that common ground
for the common good. The health care system as it currently exists is
not sustainable for the long-term and this Nation has a host of serious
challenges that cry out for attention--jobs for our people, renewed
transportation funding for our highways, expansion of our technology,
and diversification of our economy.
Unfortunately, as long as the needs of the people can be subverted by
special interests, financed by donors who operate in secrecy without
any accountability to the American public, I worry that we will see
little more than the same polarization that has dominated this Nation
for months.
Free speech is a wonderful American right that must be protected. But
much of the speech we have been witnessing of late has been anything
but free. It has been well-financed by special interests whose hands
are in the pockets of political operatives, and their motivation is not
the preservation of health care for our citizens, but, instead, the
preservation of power for themselves. Worse still, to the degree that
these operatives are able to bend government to suit their own
purposes, you can be sure that others will line up to use the same
tactics for their own good.
This is bad for West Virginia. And it is bad for our Nation.
Throughout my years of hard work for the people of West Virginia, I
have worked with Republicans, Democrats, and Independents alike, always
focused on the needs of southern West Virginia and the Nation. In all
that time, I have used my experience, honesty, and integrity to sustain
jobs for our coal miners, to ensure their health and safety and that of
their homes and their families. I have fought to expand our job base
and to build improved infrastructure, to advance technology, ensure
veterans care, improve education, and protect our God-given natural
resources, including the unborn.
Today, I call for an end to the polarization. We must put away our
personal interests, set aside our differences, and do the People's
work. We must come together for the common good, using common sense.
Ms. SUTTON. Mr. Speaker, every year 45,000 people in this country die
because they do not have insurance coverage, and in this great nation
it should not be that way. And, on this day, in this moment, we have
been called to stand up and vote to put an end to that sad reality.
This is the moment when we will finally take the long-overdue step of
ending the unconscionable practices of the insurance companies, who
through their greed and disregard have enjoyed record profits even as
American families have suffered, sometimes fatally because of their
actions.
I support this legislation because it will put a stop to the
discriminatory practices by insurance companies that deny care based on
pre-existing conditions and impose outrageous premium increases on
American families.
I support this legislation because it will cap out-of-pocket expenses
that insurance companies impose on our constituents forcing many into
bankruptcy when they or their children are stricken by illness or
injury.
I support this legislation because it is a vote to stop insurance
companies from inflicting lifetime caps on people who have paid for
insurance, only to find that it was not there for them when they needed
it most.
I support this legislation, because it will strengthen the solvency
of Medicare, lower drug costs and close the donut hole for our seniors,
and has the support of the AARP.
This legislation will make health insurance more affordable and
accessible for small businesses and individuals.
This legislation will finally curb the perpetual, skyrocketing costs
of health care that have been drowning far too many American families
for far too long.
This measure will reduce our deficit by more than $1.3 trillion in
the next two decades.
I support this legislation because within the 13th District of Ohio,
which I am so honored to serve, it will improve coverage for 420,000 of
my constituents with health insurance.
[[Page H1909]]
It will give tax credits and other assistance to up to 154,000
families and 13,200 small businesses to help them afford coverage.
It will improve Medicare for 107,000 beneficiaries, including closing
the donut hole. ``It will extend coverage to 33,500 uninsured residents
of the 13th District.
It will guarantee that 9,000 residents with pre-existing conditions
can obtain coverage.
It will protect 1,700 families from bankruptcy due to unaffordable
health care costs. ``It will allow 45,000 young adults to obtain
coverage on their parents'' insurance plans.
It will help support 3 community health centers in the 13th District
and reduce the cost of uncompensated care for hospitals and other
health care providers by $34 million annually.
For all of these reasons, this is the day, this is the moment, and I
am honored to support this health care measure.
Ms. VELAZQUEZ. Mr. Speaker, for too long, working families have lived
in fear that they are just one illness away from financial ruin. For
too long, the men and women in my home state of New York have watched
their premiums skyrocket, with family rates up 97 percent in the last
decade. For too long, Latinos have been left behind, suffering the
highest uninsured rate of any other community. Tonight, it is time to
say enough.
It is time to say enough to the discriminatory policies that charge
women and minorities more money for the same services. It is time to
say enough to a system that has pushed more than 2.5 million New
Yorkers over the brink and into the ranks of the uninsured. And it is
time to say enough to a status quo that robs Americans of the peace of
mind that can only come from knowing this--they, and they alone, are in
charge of their own well-being.
Mr. Speaker, this bill gives every American that autonomy. For the
Latino community, it delivers coverage to 8.8 million people. In my
home district, it improves options for 324,000 residents, and expands
care to 86,000 more. For 16,000 people with preexisting conditions, it
allows them to buy affordable health plans right away, promising them:
Never again. Never again can you be denied coverage. And for 4,300 of
my district's seniors paying full price for prescription drugs, it
closes the Medicare donut hole.
Meanwhile, this bill invests in New York's network of community
health centers. In my district alone, 33 clinics will see critical
improvements, meaning more options for the men and women of Brooklyn,
Queens and the Lower East Side. And at the end of the day, Mr. Speaker,
isn't that what this legislation is all about--options?
The Patient Protection and Affordable Care Act will deliver better
choices--not just for New Yorkers, but for all Americans. With the
passage of health care reform, we are finally answering a decades-long
cry for help. We are finally empowering the American people with
quality, affordable options that put them in the driver's seat, and I
urge support of this landmark legislation.
Mr. BISHOP of Georgia. Mr. Speaker, I have decided to support the
health reform legislation because it represents an historic opportunity
to make health care more accessible and affordable now and into the
future. I base this decision not on what is popular, but on what I
believe is in the best interest for Georgia's Second Congressional
District both in the short- and long-term.
Throughout this process, I have solicited the views of people both
supporting and opposing health care reform. I have heard from doctors
and patients, small business owners and the CEOs of large corporations,
as well as residents of rural and urban areas. I also have heard from
the healthy and the sick, the young and the old, and the rich and the
poor. I thank each of you who shared your views with me, and I have
listened to your opinions.
In my district there are more than 83,000 uninsured residents who
will receive health insurance coverage under this bill. There are
14,500 uninsured individuals who have a pre-existing medical condition
such as cancer, heart disease, and diabetes and who will now no longer
be denied affordable health insurance coverage. In addition, there are
12,100 small business owners in my district who will qualify for tax
credits to help employees afford health care.
My district is also home to 96,000 senior citizens who will benefit
from a stronger Medicare program whose solvency is extended to 2026.
There are 6,600 Medicare beneficiaries who will now be able to afford
their prescription drugs with the closure of the Part D 'donut hole.'
And, through the health care reform bill, 181,000 households in
Southwest Georgia could qualify for tax credits to purchase health
insurance through Medicaid, employer sponsored insurance, or other
acceptable coverage. For these people and for millions of Americans
like them, I have decided to support the health care reform bill.
Some people have asked how I could be a fiscally conservative Blue
Dog Democrat and still support the health reform bill. I do not know
how I could be a Blue Dog Democrat and not support this bill. According
to the nonpartisan Congressional Budget Office, the bill will reduce
the deficit by $138 billion over the next 10 years and $1.2 trillion in
the decade after that. It includes tough provisions attacking waste and
fraud in the Medicare and Medicaid programs, including some proposed by
Republicans. It will slow the growth in health care costs that are
becoming an increasing burden on families, businesses, and governments.
And the legislation will benefit rural America by boosting mandatory
funding for community health centers by $11 billion over five years and
making significant investments in the training of primary care doctors.
This bill is not perfect. We cannot, however, let the perfect be the
enemy of the good. Nor can we allow fear, misinformation, political
motivation and partisanship to prevent us from taking the necessary
steps to improve our health care system. I believe that we have a moral
obligation to ensure that all Americans, regardless of race, ethnicity,
geography, or income, receive the health care they need to lead healthy
and productive lives.
As a man of faith, I know that Jesus taught us to provide and care
for others, especially the `least of these' who often have few
advocates. In addition, when I ask myself, `What would Jesus do if he
represented the Second Congressional district, and had the opportunity
to vote to enable more than 32 million uninsured Americans to receive
health insurance?' I believe He would take care of this immediate need
of the people--not let them fend for themselves while we start over or
do nothing. This legislation goes a long way toward living up to this
moral principle, and I am proud to support it.
Ms. EDDIE BERNICE JOHNSON of Texas. Mr. Speaker, I rise to claim time
in support of the Reconciliation Bill and the Senate amendments to the
Patient Protection and Affordable Care Act.
Health care in the United States has degraded in accessibility and
quality to the extent that we are a nation in crisis. Change is needed
to truly make progress toward a healthier America, and the time for
change is now.
We are the closest in 60 years of legislative efforts to provide
access to health care for all Americans. We must pass this legislation
for the people.
It is time to place compassion and dignity over corporate greed.
My experiences as a legislator--and as a nurse--have provided a
unique vantage point from which to discuss this issue. I have seen
first-hand the state of affairs of our health care system.
We cannot sustain the current system as premiums rise, prescription
prices soar, and medical bankruptcies increase as services decline.
Texas leads the Nation in uninsured, including the highest rate of
uninsured children, and I am here today to stand up for my constituents
who desperately seek access to care.
Thousands of families are crushed by the growing cost of health care.
This legislation reins in health care costs for families and businesses
and reduces the deficit.
We have come to a point where we must choose consumers over insurance
companies. Insurance companies have held the public hostage for many
years, controlling and rationing care. It is time to give citizens the
right to control their own health care.
I stand in strong support of the legislation and urge my colleagues
to do the same.
Mr. HALL of Texas. Mr. Speaker, as we enter the most important and
eventful week of the thirty years I've been up here--I think of the
consequences of the votes we will cast--both Republican and Democrat.
When we passed the health bill on this very floor--the Democrats--
with a 40 vote advantage on the House Floor--passed H.R. 3962 with a 5
vote advantage--which showed that the outrageous health bill had been
lessened in severity in the Commerce Committee--and was softened up
enough for the Senate to kill it. Then, a series of Senators negotiated
gifts they were not entitled to--each receiving a different
consideration--into being the coveted 60th vote. If we take the Floor
back--I would favor subpoenaing those who may have made the overtures
to compare it to the law of bribery or corrupt deals. I would send the
results to the Federal and State Prosecutors. The bribery penalty as
set out in 18 U.S. Code Section 203 ``is imprisonment for not more than
a year and a civil fine of not more than $50,000 for each violation.''
I consider offering a bribe--for a personal benefit--as worse than
accepting one; let's clean up the United States Congress--and listen to
our people whose only request is to take back our country.
Webster's Dictionary defines ``bribe'' as money or favor given or
promised to a person in a position of trust to influence their judgment
or conduct.
Mr. MARIO DIAZ-BALART of Florida. Mr. Speaker, I rise today to
express my strong opposition to the eventual government takeover of
health care that took place on the floor of the House today.
[[Page H1910]]
Though I strongly believe that America needs health care reform, I
cannot in good conscience cast a vote for a bill that will take our
country down the path of bankruptcy.
This deeply flawed legislation raids Medicare, which faces insolvency
in 2017, by over half a trillion dollars in order to create a massive
new entitlement program. It raises taxes on our families and small
businesses by over half a trillion dollars. It will lead to increases
in insurance premiums, increase overall spending on health care by over
$200 billion and will result in job losses. This bill will also
increase the national debt and deficit, leaving our children and
grandchildren to pay the price.
Today Democrat leadership abused and manipulated the legislative
process for political gain, in an effort to force an eventual
government takeover of health care that the American people do not
want. This legislation was drafted in secret and is loaded with
backroom deals for certain Members of Congress and special interests.
The American people need, demand and deserve health care reform that
will increase access, improve quality and lower costs. What the
American people do not want is this ill-conceived legislation that will
bankrupt our country and leave a lasting negative impact on generations
to come.
Nothing is more sacred in this country then our freedom and
democracy. These are the fundamental principles that make America the
greatest country in the world, and I cannot and will not vote for
legislation that jeopardizes the freedom, democracy, prosperity and
opportunity of future generations of Americans.
Mr. COSTELLO. Mr. Speaker, we meet today for what will truly be a
historic debate and vote on national health care reform. Like the
passage of Social Security in 1935 and Medicare in 1965, it is sure to
be one of a handful of votes that will stand the test of time as of
great national significance. Also like those votes, the public debate
surrounding national health care reform has engendered great passion on
both sides, often generating more heat than light, but instructive all
the same, as we must listen to all viewpoints as we contemplate major
changes that will affect the entire country.
Today's vote is a major milestone in what has been a decades-long
effort to ensure access to quality health care for all Americans. In my
district, 34,000 people are uninsured and use the hospital emergency
room for treatment. Nine thousand people have a pre-existing condition
that precludes them from getting insurance. Meanwhile, health insurance
premiums have increased 131 percent over the last decade while wages
have gone up only 38 percent. While the process over the last 14 months
to develop health care reform legislation has been far from perfect, it
is undeniable that our current health care system is broken, and we
must take action to fix it. Toward this goal, I will vote in support of
H.R. 3590 and H.R. 4872.
This has been the hardest decision regarding a vote I have had to
make during my service in the House of Representatives. During that
time, I have strived to serve the people I represent with diligence and
integrity, while remaining true to my core individual beliefs.
One of those core beliefs is my support of protecting the unborn. I
along with Congressman Bart Stupak (D-MI) and other pro-life Democrats
have worked hard through the passage of the House bill and since the
passage of the Senate bill to ensure that current law Hyde amendment
abortion restrictions are applied to the final legislation. However, we
were successful in convincing President Obama--a pro-choice President--
to issue an executive order that clearly states that the Hyde amendment
will apply to the bill. This is a highly significant act. In addition,
a colloquy on the House floor clearly stated that this is the intent of
Congress. With these changes, I believe we have accomplished our goal.
This belief is shared by the Catholic Health Association, NETWORK--a
national Catholic social justice lobby, the Catholic Sisters--60
Catholic women religious leaders representing 59,000 Catholic Nuns, and
Democrats for Life.
I stated that I would not vote for the Senate-passed bill in its
current form. With the presidential executive order approving the Hyde
abortion language and the fact that H.R. 4872 eliminates the
``Cornhusker Kickback'' and other state-specific promises, combined
with assurances from the Senate that H.R. 4872 will pass that body, I
feel I can now support the Senate bill as amended.
The fact is that this may be our last best chance to address a health
care system that is unsustainable, that is spending $1 billion annually
on medical costs for the uninsured while insurance premiums rise
uncontrollably. Our current system is grossly inefficient and
jeopardizes our future economic health. This legislation will insure 32
million additional Americans, eliminate pre-existing condition
restrictions, allow for the interstate sale of health insurance,
eliminate lifetime caps on insurance benefits, allow dependent children
to stay on their parents' insurance until age 26, and improve health
care for seniors, all while reducing our budget deficit by $138 billion
over the next 10 years, and by $1.2 trillion over the next 10.
While the legislation will allow those that have health insurance to
keep it, it will also end the fear that so many uninsured Americans
have of becoming sick--of having to use their life savings or declare
bankruptcy to pay for a medical emergency. It can be the difference
that allows the disabled to live with dignity, and provides workers the
confidence to reach their maximum professional potential.
Mr. Speaker, after much deliberation, it is clear to me that we must
take this opportunity to improve the provision of health care in our
country. While it is a difficult thing to do, it is unquestionably the
right thing to do, and I am confident that history will reflect this
fact.
Mr. GOODLATTE. Mr. Speaker, nearly two months ago President Obama
stood here before the Members of the House of Representatives, the
Senate, the Supreme Court Justices, his own Cabinet Members and
millions of Americans who were watching on television to deliver his
first State of the Union address. In that speech he declared that as
economic uncertainty continues to plague our Nation the government must
focus on policies that promote economic growth and job creation. My how
things have changed in just two short months.
Congress should be working to reduce the tax and regulatory burdens
that hinder small businesses and ultimately overall economic growth and
job creation. Instead, over the loud objections of a majority of
Americans, the Majority continues to advance their health care reform
proposal which sets the tone for a Washington takeover of the health
care system. This legislation which contains a multitude of new federal
regulations, mandates, new big government programs, and a significant
increase in federal spending and debt, will be extremely detrimental to
American businesses and particularly our small businesses, which will
make job losses even worse.
The legislation includes over $569 billion in tax increases and over
$523 billion in Medicare cuts. This includes $52 billion in new taxes
on employers, including small businesses, that cannot afford to provide
health coverage or that don't offer coverage. The effect of this type
of tax, similar to a payroll tax increase, would ultimately fall
squarely on workers in the form of lower wages or reduced employment.
Additionally, the legislation includes $17 billion in new taxes on
Americans who do not comply with the individual insurance mandate which
is sure to further stifle economic growth.
In fact, 130 economists from all across the country sent President
Obama a letter explaining how this legislation is a job-killer. In
their letter, the economists stated that the insurance mandate and the
tax increases, among other things, will ``constrict economic growth and
reduce employment'' while ``increasing spending on health care and
increasing the cost of health coverage''.
That is why I strongly support an alternative proposal which allows
for the purchase of health insurance across state lines, allows
individuals and small businesses to join large pools to get more
competitive rates, provides tort reform to cut down the high cost of
defensive medicine, allows full tax deductibility of health insurance
premiums, portability of health insurance and protection against pre-
existing condition exclusions. In addition, I support health insurance
tax credits for individuals and families who don't have access to
employer-based health insurance, increasing the number of community
health centers, and encouraging the use of health information
technology to achieve greater efficiencies.
Congress should not be pushing this government takeover of health
care that will inflict even more harm on our Nation's economy, making
job losses even worse. Instead Congress must focus on strategies that
help Americans obtain the best quality health care at the least cost,
and ensure that the government fosters increased access to quality care
based on individual choice, not by taking away choices from people on
the grounds that government knows best.
Mr. SMITH of New Jersey. Mr. Speaker, for those of us who recognize
abortion as lethal violence against children and the exploitation of
women, nothing less than a comprehensive prohibition on public funding,
promotion and facilitation of elective abortion in any federal health
program, including the bill under consideration today, satisfies the
demands of social justice.
The Stupak-Pitts Amendment which passed 240-194-1 ensures that not
some, but all the elements of the Hyde amendment applies to the
programs that are both authorized and appropriated in this bill.
By now, I trust that all members fully understand that because
programs in Obamacare are both authorized and appropriated in this
legislation, the actual Hyde Amendment has no legal affect. It only
affects Labor HHS not this massive expansion of government funded
health care.
[[Page H1911]]
Regrettably the language that emerged from the Senate is weak,
duplicitous and ineffective, not by accident, but by design. It will
open up the floodgates of public funding for abortion in a myriad of
programs resulting in more dead babies and wounded moms than would
otherwise have been the case.
Because abortion methods dismember, decapitate, crush, poison, starve
to death and induce premature labor, pro-life Members of Congress, and
according to every reputable poll, significant majorities of Americans
want no complicity whatsoever in this evil. Obamacare forces us to be
complicit.
Abortion hurts women's health and puts future children subsequently
born to women who aborted at significant risk. At least 102 studies
show significant psychological harm, major depression and elevated
suicide risk in women who abort.
Recently, the Times of London reported that, ``[S]enior . . .
psychiatrists say that new evidence has uncovered a clear link between
abortion and mental illness in women with no previous history of
psychological problems.'' They found, ``that women who have had
abortions have twice the level of psychological problems and three
times the level of depression as women who have given birth or who have
never been pregnant . . .''
In 2006, a comprehensive New Zealand study found that 78.6 percent of
the 15-18 year olds who had abortions displayed symptoms of major
depression as compared to 31 percent of their peers. The study also
found that 27 percent of the 21-25 year old women who had abortions had
suicidal idealizations compared to 8 percent of those who did not have
an abortion.
At least 28 studies--including three in 2009--show that abortion
increases the risk of breast cancer by some 30-40 percent or more yet
the abortion industry has largely succeeded in suppressing these facts.
Abortion isn't safe for subsequent children born to women who have had
an abortion. At least 113 studies show a significant association
between abortion and subsequent premature births. For example a study
by researchers Shah and Zoe showed a 36 percent increased risk for
preterm birth after one abortion and a staggering 93 percent increased
risk after two.
Similarly, the risk of subsequent children being born with low birth
weight increases by 35 percent after one and 72 percent after two or
more abortions. Another study shows the risk increases 9 times after a
woman has had three abortions.
What does this mean for her children? Preterm birth is the leading
cause of infant mortality in the industrialized world after congenital
anomalies. Preterm infants have a greater risk of suffering from
chronic lung disease, sensory deficits, cerebral palsy, cognitive
impairments and behavior problems. Low birth weight is similarly
associated with neonatal mortality and morbidity.
Unlike both the Hyde Amendment and what would be the effect of the
Stupak-Pitts amendment, the Senate passed bill permits health care
plans and policies funded with tax credits to pay for abortion, so long
as the issuer of the federally subsided plan collects a new,
congressionally mandated fee from every enrollee in that plan to pay
for other peoples abortions. Requiring the segregation of funds into
allocation accounts--a mere bookkeeping exercise touted by some as an
improvement to the new pro-abortion funding scheme--does absolutely
nothing to protect any victims--baby or mother--from publically funded
abortion.
The Senate passed bill creates a new Community Health Center fund and
appropriates at least $7 billion for Community Health Centers (CHC).
Again recognizing that the Hyde Amendment does not apply to this bill
and absent enactment of the Stupak-Pitts amendment, it is clear that
the 1,250 CHC clinics (among the most effective means of reaching the
poor and underserved with basic health care) will likely be compelled
either by the Obama Administration or the courts or both to fund
abortion on demand at CHC sites. There is no statutory protection
against this abuse in the Senate-passed bill.
Additionally, under the federal employee health benefits plan, which
includes Members of Congress, since 1984, no funds may be used for
abortion or the administrative expenses in connection with any health
plans that provide any benefit or coverage for abortions or even the
administrative expense, except in the case of rape, incest or to
protect the life of the mother.
The Office of Personnel Management (OPM) administers the program.
The Senate-passed bill on the other hand creates a huge new program
administered by OPM that would manage two or more new multi-state or
national health plans. The bill stipulates that at least one plan not
pay for abortion. Which only begs to question: what about the other new
multi-state plans administered by OPM? Why can those federally
administered plans include funding abortion on demand? This represents
a radical departure from current policy.
Additionally, other appropriated funds in the bill have no Hyde/
Stupak-Pitts type protections either including $5 billion for a
temporary high risk health insurance fund and $6 billion in grants and
loans for health cover co-ops. Pro-life members who vote for this bill
will roll the dice on this one.
When the bill left the House, it contained the Hyde-Weldon language
protecting health care providers who refuse to participate in abortion
against discrimination by government entities. The Senate passed bill
instead only includes more narrow text that prevents discrimination by
a ``qualified health plan'' on the Exchange. This narrow language was
included in the House bill, but without the additional protections
against discrimination by federal and state governmental entities, pro-
life health care providers are not fully protected.
Then there's the Mikulski Amendment, Sec. 2713, which empowers the
HHS Secretary with broad new authority to compel private health care
plans in America to cover ``preventable'' services. When Senator Ben
Nelson suggested that abortion not be included in the so-called
preventative services mandate, Ms. Mikulski said no--raising a serious
red flag that abortion is being postured as ``preventable abortion
service in the future''--after all, abortion prevents a live birth.
Abortion as preventative health care isn't new.
And as far back as 1976, Dr. Willard Cates, Jr. and Dr. David Grimes,
then with CDC, presented a paper to a Planned Parenthood meeting,
entitled: Abortion as a Treatment for Unintended Pregnancy: The Number
Two Sexually Transmitted ``Disease''. To call pregnancy sexually
transmitted disease; to call abortion a treatment or a means of
prevention for this ``disease'' is barbaric.
Abortion isn't health care--preventative or otherwise.
Mr. Speaker, we live in an age of ultrasound imaging--the ultimate
window to the womb and its occupant. We are in the midst of a fetal
health care revolution, an explosion of benign innovative interventions
designed to diagnose, treat and cure disease or illness any unborn
child may be suffering.
Unborn children are society's youngest and most vulnerable patients.
Obamacare should do them no harm. Tragically, it does the worst harm of
all. It kills them.
Mr. FILNER. Mr. Speaker, I rise in support of this bill and I would
like to take the opportunity to remind America's veterans that the plan
will not affect the VA health care system. I continue to work in
concert with leaders in the House of Representatives to ensure that
veterans receive the world-class health care services they have so
bravely earned.
Let me be clear: enrolled veterans meet the individual responsibility
requirements under the bill to maintain quality health coverage.
I firmly believe all of our citizens should have access to health
care. I am proud that Congress has crafted a plan to bring stability
and security to Americans who have insurance today, and affordable
coverage to those who do not. This plan, however, will not jeopardize
the current health care services and benefits provided by VA. We will
keep our promise to our Nation's heroes of the past, present, and
future.
I was pleased to sign a letter with House Armed Services Chairman Ike
Shelton, House Ways & Means Chairman Sander Levin, House Education &
Labor Chairman George Miller, and House Energy and Commerce Chairman
Henry Waxman affirming that current health care reform legislation does
not undermine or change the Department of Veterans Affairs mandate to
provide comprehensive health care to veterans. I would like to submit
this letter, along with statements from the Vietnam Veterans of America
and AMVETS and a statement from General Eric Shinseki, Secretary of the
VA, affirming this fact for the Record.
Congress of the United States,
Washington, DC, March 21, 2010.
Hon. Louise Slaughter,
Committee on Rules, The Capitol,
Washington, DC.
Dear Chairwoman Slaughter: The House Democratic leadership
asked our committees to review HR 3590 and HR 4872 to assess
the impact of the bills on the health care provided by the
Department of Defense and the Department of Veterans Affairs.
Our reviews of HR 3590 and HR 4872 lead us to believe that
the intent of the bills was never to undermine or change the
Department of Defense and Department of Veterans Affairs
operation of their health care programs or interfere with the
care that our service members receive under TRICARE. However,
we commit to look into this issue further to ensure that no
unintended consequences may arise and to take any legislative
action that may be necessary.
HR 3590, as drafted, does not specifically mention that
TRICARE coverage meets the individual responsibility
requirement. but such coverage would satisfy the requirements
of this bill. To affirm that this is the case, the U.S. House
of Representatives unanimously passed HR 4887, the TRICARE
[[Page H1912]]
Affirmation Act, which provides assurances to the American
people that care provided to those in the military and their
families, as well as military retirees under age 65 and their
families, would indeed meet the requirement for coverage.
The members of our nation's military sacrifice much to
defend us all. We commit to these dedicated service members
and their families as well as our veterans that we will
protect the quality healthcare they receive,
Sincerely,
Bob Filner,
Chairman, Committee on Veterans' Affairs.
George Miller,
Chairman, Committee on Education and Labor.
Henry Waxman,
Chairman, Committee on Energy and Commerce.
Ike Skelton,
Chairman, Committee on Armed Services.
Sander Levin,
Chairman, Committee on Ways and Means.
____
March 21, 2010.
Vietnam Veterans of America Applauds Passage of Skelton Bill Ensuring
Protection of TRICARE, VA Health Care, and CHAMPUS; Decries ``Scare
Tactics''
Washington, DC.--`` We thank and applaud passage of H.R.
4887 yesterday in the House of Representatives, by a vote of
403-0. Passage of this bill ensures that health care programs
for veterans, active duty military, retired military, and
their families/survivors will not be affected negatively by
the pending health care reform legislation.'' said John
Rowan, National President of Vietnam Veterans of America
(VVA).
``It is unfortunate that some continue to raise what is now
is even more clearly a false alarm that is apparently meant
to frighten veterans and their families in order to prompt
them to oppose the pending legislation. While there is
legitimate debate as to whether or not the pending health
care measures should become law, VVA does not appreciate
spreading rumors that are not accurate by any political
partisan from any point of the political spectrum,''
continued Rowan.
``Last summer there was a similar incident, also involving
partisans in the health care reform debate, that VVA soundly
condemned. We said then: ``It is our hope that sane minds
reject fear-mongering, and that veterans recognize these
scare tactics for what they are,'' Rowan said. Rowan
concluded by saying: ``VVA has always worked hard for justice
for veterans of all generations, and their families. We have
always, and will continue to, work with public officials
representing all political parties and points of view. Issues
affecting veterans and their families are not, should not,
and must not become partisan footballs to bat around. VVA
decries any effort, by anyone, that would do just that.''
____
Department of Veterans Affairs,
March 21, 2010.
Statement from VA Secretary Eric K. Shinseki
As Secretary of Veterans Affairs, I accepted the solemn
responsibility to uphold our sacred trust with our nation's
Veterans. Fears that Veterans health care and TRICARE will be
undermined by the health reform legislation are unfounded. I
am confident that the legislation being voted on today will
provide the protections afforded our nation's Veterans and
the health care they have earned through their service. The
President and I stand firm in our commitment to those who
serve and have served in our armed forces. We pledge to
continue to provide the men and women in uniform and our
Veterans the high quality health care they have earned.
President Obama has strongly supported Veterans and their
needs, specifically health care needs, on every major issue
for these past 14 months--advance appropriations, new GI Bill
implementation, new Agent Orange presumptions for three
additional diseases, new Gulf War Illness presumptions for
nine additional diseases, and a 16% budget increase in 2010
for the Department of Veterans Affairs, that is the largest
in over 30 years, and which has been followed by a 2011 VA
budget request that increases that record budget by an
additional 7.6%.
To give our Veterans further assurance that health reform
legislation will not affect their health care systems, the
Chairmen of five House committees, including Veterans Affairs
Chairman Bob Filner and Armed Services Chairman Ike Skelton,
have just issued a joint letter reaffirming that the health
reform legislation as written would protect those receiving
care through all TRICARE and Department of Veterans Affairs
programs.
____
AMVETS Applauds Skelton Bill To Protect Military Health Care
Lanham, Md. March 21, 2010--AMVETS leaders applauded the
passing of H.R. 4887, introduced by Rep. Ike Skelton, D-Mo.,
that will protect specific health care benefits of military
veterans, members of the Armed Forces and their families.
AMVETS National Legislative Director Raymond Kelly said
Sunday that AMVETS leaders have always understood the intent
of H.R. 3590: The Patient Protection and Affordable Care Act,
and believed it would not compromise the health care benefits
of American Veterans.
``AMVETS continues to share the opinion of Department of
Veterans Affairs Secretary Eric Shinseki and other VA and
Department of Defense leaders that health care reform
legislation does not threaten the veterans' community,'' said
Kelley. ``The successful passing of Rep. Skelton's
legislation only solidifies our belief and erases any and all
doubt of potential harm.''
Kelly said AMVETS will continue to monitor the debate to
ensure the Senate version of H.R. 4887 also passes.
Ms. HIRONO. Mr. Speaker, today we take a stand for hard-working
middle class families who deserve a better value for their health care
dollar. We take a stand for better health care for America's seniors.
We take a stand for those who have been denied insurance coverage
because of a preexisting condition or whose insurance is rescinded when
they need it most.
This has been a difficult debate. There are strong, personal feelings
about the issue of health care, because it affects all of us. This
makes it even more important that we focus on the substance of health
care reform, rather than engage in demagoguery, name calling, and
worse. Republicans and Democrats alike know that our health care system
is broken and not sustainable. Our country spends more on health care
than any other developed country and we fall far below these other
countries in the health of our people.
H.R. 4872 and the Senate health care reform bill, H.R. 3590, are not
perfect, but they are a step in the right direction. The health
insurance reform measure achieves the three key goals of affordability
for the middle class, accessibility for all Americans, and
accountability for the insurance industry.
More than 350 organizations support the health insurance reform
legislation that we are voting on today. They include: the American
Medical Association, AARP, Catholic Health Association, Main Street
Alliance, Federation of American Hospitals, National Association of
Public Hospitals and Health Systems, American College of Physicians,
Paralyzed Veterans of America, American Heart Association, American
Cancer Society Cancer Action Network, American Diabetes Association,
American Nurses Association, Families USA, National Committee to
Preserve Social Security and Medicare, National Women's Law Center,
Consumer Federation of America, and the Consumers Union.
Once this bill is passed, Americans will see immediate benefits:
seniors will start to see immediate relief from high prescription
prices with a $250 rebate for Medicare beneficiaries who hit the donut
hole; preventative services and immunizations will be free under
Medicare right away--eliminating co-payments for preventative services
and exempting preventative services from deductibles; and small
businesses that provide coverage to their employees will be eligible
for a tax credit of up to 35% of premiums. The bill will also ban
insurers from denying coverage to children with pre-existing conditions
and eliminates lifetime limits and restrictive annual limits on
coverage.
These are real reforms yielding real benefits to people who are not
getting their money's worth from the current system. It will soon be
much harder to mischaracterize what this effort to change the health
care system has been about once reform is enacted and the benefits
accrue.
I was appalled at the news that my colleagues John Lewis, Andre
Carson, Emanuel Cleaver, and Barney Frank were verbally insulted and in
one instance spat on by anti-health care reform protestors yesterday.
The ugliness that this behavior exemplified reminded me of why ``Live
Aloha'' is more than a motto to us in Hawaii. The Hawaiian word aloha,
has deep meaning in my state; it is far more than hello or goodbye. To
``Live Aloha'' is to also have respect for yourself and respect for
others, especially those with whom we disagree. To treat each other
with decency--not hatred, or racism, or bigotry--is to ``Live Aloha.''
I'm proud to represent a state where we strive toward that ideal.
My office has taken many calls and received many emails and letters
on health care reform. A call that my office received on Friday was
particularly heartfelt. It was from a woman on the island of Kauai who
called to tell me that she and her 93 year-old friend both wanted me to
stay strong and to vote in support of health care reform. I mention
this particular call because it reminded me of the people and places I
represent, who I fight for every day, and what this health care debate
is all about.
In his recent address to the Democratic Caucus, President Barack
Obama quoted President Abraham Lincoln who said, ``I am not bound to
win, but I'm bound to be true. I'm not bound to succeed, but I'm bound
to live up to what light I have.'' This bill calls us to be true to the
millions of Americans who want and need enlightened health care reform.
It is a privilege to vote for H.R. 4872.
[[Page H1913]]
Mr. ISRAEL. Mr. Speaker, I rise in support of this bill for one
fundamental reason. It is-simply the right thing to do. Not for my
Party, not for the President, not for the Speaker, not for me. But for
the people I represent. The middle class and working families; the
backbones of our economy--small businesses--challenged by rising health
costs.
Few debates have been as long and as passionate as this one. Since
last August I have heard the strong voices on both sides of this issue.
I have listened to the angry chants of opponents of the bill at Town
Hall meetings. I have read the mail from people who insist this is a
march towards socialism, that it is a dangerous experiment, that it
involves government death panels who will deny senior citizens the
life-saving health care they need. I have watched protesters march
outside my district office on Long Island. I have seen the repugnant
signs here in Washington comparing health care to the Holocaust.
I have seen and heard it all. But I have also heard others. They are
the average Long Islanders--not rich, not poor, but usually somewhere
in between--who live in quiet desperation and concern.
The small business owner on Long Island who told me he just received
a 22 percent increase in health insurance premiums and agonizes at the
prospect of either scaling back the care he provides his workers or
scaling back the workers he pays. Under this bill, his business will
receive a tax credit to help him provide insurance to his workers. And
he will be able to shop for competitive rates and services in a new
market-driven ``Health Insurance Exchange.''
The woman who thought health care worked pretty well for her, until
her daughter was diagnosed with breast cancer. She's been forced to
deal with high medical costs to care for her daughter. But, under this
bill, she will not have to worry about an insurance company that
refuses to pay for her chemotherapy.
The middle class family with two kids just out of college who are
having trouble finding a job that provides health insurance. Under this
bill, those young adults can get coverage on their parents' plans until
they turn 26.
The retired plumber on the block where I live. One day he came to my
house. I thought he wanted to debate this bill with me. Instead, he
said: ``I wish you would pass this now. Don't these people know that if
they lose their jobs they lose their health care?''
And just yesterday, Mr. Speaker, a small business owner called me
with concerns and plentiful questions about the legislation we will
vote on today. After I explained it, he said: ``There's been too much
confusion about this bill. I wish it had been explained.''
He is right. This bill has changed in over a year of debate.
Sometimes in an effort to accept bipartisan recommendations. Sometimes
to reduce its cost. While one side has had the responsibility to
improve the bill, the other side has taken the opportunity to brand it
with mischaracterizations. But now the ink is dry, Mr. Speaker. And the
dry ink of this bill represents the best hope to protect the middle
class and working families I represent. The small business owner in
East Northport who now has a level playing field when shopping for
insurance. The family in Sayville who can now keep a child insured
until the age of twenty-six. The senior in Deer Park whose drug costs
will be covered. The accountant in Huntington who lost his job but will
be able to shop for affordable health care.
This bill will improve coverage for 485,000 of my constituents with
coverage through their employer, give tax credits to as many as 81,000
families and 21,000 small businesses to make health care affordable in
my district, and extend coverage to 29,000 uninsured residents of the
towns I represent.
This bill will reduce our debt. Yesterday, the Congressional Budget
Office certified that the bill is fully funded and will actually reduce
federal deficits by $143 billion in the first ten years and over a
trillion dollars in the next ten.
This bill is an urgent reversal from eight years of ignoring the
crisis. Between 2000 and 2008, health insurance premiums doubled,
insurance company profits quadrupled, and an additional 6 million
Americans became uninsured. As a result, the leading cause of personal
bankruptcy today is unpaid medical bills. Without action, these trends
will grow worse.
These are the middle class families and businesses that have always
expanded our economy. But rising health costs and insecurity have
undermined the middle class. This bill will provide them with the basic
security they need to do what they've always done: build our economy.
This vote is no different than the 1965 vote for Medicare. Back then,
when one-quarter of American seniors were living in poverty and wracked
with un-payable medical bills, there were loud voices that said, ``do
nothing'' and ``start over'' and ``vote no.'' Public opinion was
skeptical then. Had I been in Congress in 1965, and the choice was
voting for Medicare and risking my seat, or voting against Medicare and
saving my seat, I would have voted for Medicare. It became the back
bone of economic security for our senior citizens and helped build a
middle class with economic security. This is no different. No less
necessary. No less historic.
Mr. STARK. Mr. Speaker, This is a historic day. We have worked to
enact health reform in America for decades. President Johnson took a
major step when he signed Medicare into law in 1965 and guaranteed
every American age sixty-five and over quality, affordable health care.
Forty-five years later, we are about to extend that guarantee to all
Americans.
It isn't the bill I would have written. However when it comes to
legislating health insurance reform in America, we will not get
everything each of us want. This bill is a compromise that bridges the
differences among us.
I am proud to support this legislation and urge my colleagues to do
the same.
This bill builds a solid foundation. It will:
Extend coverage to 95 percent of all Americans.
Assure affordability of health insurance by providing tax credits and
cost-sharing assistance to families up to 400 percent of poverty.
Halt abuses of the health insurance industry--forcing them to compete
on quality, not just their ability to avoid covering needed health
services.
Guarantee a standard benefit package for all Americans with an annual
cap on out-of-pocket spending. No family should go bankrupt because of
medical expenses.
Create a new marketplace, called an Exchange, where people will be
able to comparison shop among health insurance plans.
Require that insurance plans spend at least a certain percentage of
their premium dollars on benefits and end discrimination by health
status, gender, occupation.
Help senior citizens by filling the Republican Medicare prescription
drug donut hole--ensuring that Medicare beneficiaries will be able to
afford their medications year-round.
We are joined in support of this legislation by a coalition of
patients, doctors, nurses, hospitals, businesses, labor unions,
children's advocates and senior citizens.
President Obama has worked tirelessly to achieve this goal and he
deserves much of the credit.
There are components I wish had turned out differently and I pledge
to continue working to improve them. In particular, I have some
concerns about Medicare.
I oppose the inclusion the Independent Payment Advisory Commission,
called IPAB. Some of my colleagues support this Commission because it
shields them from having to take tough votes when it comes to cutting
Medicare provider payments. It's my experience that Congress always
does what is needed to protect and strengthen the Medicare program.
IPAB is a dangerous provision. By statute, this Commission would be
required to hold Medicare spending to an arbitrary and unrealistic
growth rate. It is a mindless-rate cutting machine that sets the
program up for unsustainable cuts. That will endanger the health of
America's seniors and people with disabilities. It is an unprecedented
abrogation of Congressional authority to an unelected, unaccountable
body of so-called experts. I intend to work tirelessly to mitigate the
damage that will be caused by IPAB.
I am pleased that this legislation reduces government overpayments to
private health insurance plans in Medicare and that our reconciliation
negotiations improved on those savings. It still should eliminate the
overpayments. I support the choice of private plans in Medicare, but I
don't support wasting taxpayer dollars on corporate subsidies to
achieve that goal. Plans that can meet or beat Medicare should be
allowed to participate. Those that can't should be excluded. We've got
more work to be done here.
We also lost a provision in the House bill that ensured Medicare
beneficiaries in private plans would never pay higher cost-sharing for
Medicare services than if they were enrolled in traditional Medicare.
I'll be working with the Administration to see that they move forward
with steps in their authority to resolve that disparity.
I am disappointed in the lack of a public health insurance option.
This provision fell victim to the strength of the insurance industry
lobby. It would have saved taxpayers money, enhanced competition, and
increased efficiencies. That it isn't in this bill does not mean it
can't be added in the future.
These flaws are what one must expect when bringing a bill through the
US Congress that touches more than one-sixth of our economy. In the
past, we've allowed health reform to fail because of similar
imperfections. We, can't let that happen now.
Our vote today will determine whether we finally provide affordable,
quality health care to all Americans. I am proud to rise in support of
this legislation, and I urge my colleagues to join me in voting yes.
Mr. PIERLUISI. Mr. Speaker, I rise so that the record will reflect
the following point about the Medicare Advantage program and its
application in Puerto Rico. For a variety of reasons, relatively few
Medicare beneficiaries in
[[Page H1914]]
Puerto Rico are enrolled in Part B. The Medicare Payment Advisory
Commission (MedPac) has determined that, as a result, fee-for-service
reimbursement rates for providers on the Island are artifically low and
unstable. Over the past year, I have worked with the House Committee on
Ways and Means to examine ways to address this problem. In the report
accompanying the health care reform bill it approved, the Committee
candidly acknowledged the problem and urged CMS to use its existing
authority to adjust the reimbursement rates in Puerto Rico. I strongly
supported this language and believe it is still operative. Working with
Committee leadership and my colleagues, I will do everything within my
power to ensure that CMS uses its current authority to make certain
that reimbursement rates to MA providers in Puerto Rico are fair.
The language included in the House Ways and Means Committee report
is:
The phase-down of MA payments to FFS costs applies equally to all 50
states and the territories, however, Puerto Rico is a unique situation
that the Committee expects that the Secretary will use authority under
current law to examine. Specifically, very few Medicare beneficiaries
in Puerto Rico choose to enroll in Part B; instead, MA plans buy down
the Part B premium for enrollees and therefore many Medicare
beneficiaries enroll in MA to receive all of their Medicare services.
With only a small population enrolled in Part B through traditional
Medicare, the county FFS expenditures calculated by the Secretary are
artificially low and unstable from year-to-year. Therefore, the
Committee expects that when calculating county FFS rates in Puerto
Rico, the Secretary will use utilization and expenditure data from MA
plans under current authority and adjust these rates and risk scores
appropriately.
Mr. SMITH of Texas. Mr. Speaker, by a 12-point margin, Americans say
the Administration's health care plan is a ``bad idea,'' according to a
new NBC News/Wall Street Journal survey.
And the number of people who call the health plan a ``bad idea'' has
reached a new high.
But you won't hear about this from the national media--not even NBC,
who conducted the poll. During a report about the survey on NBC's
Nightly News, anchor Brian Williams failed to mention this finding.
Other polls show even greater opposition to the Administration's
plan. According to Investor's Business Daily, Americans want Congress
to ``start fresh'' by 61 percent to 32 percent.
NBC and the national media should give the American people the facts
about health care, not hide them.
Mr. POE of Texas. Mr. Speaker, in a new survey of doctors published
by The New England Journal of Medicine--nearly half of all primary care
physicians said they may leave the medical profession if Obama-care
passes.
Doctors are getting railroaded out of practice now. Medicare doesn't
pay the cost to keep their doors open. The new healthcare scheme makes
it worse. Some doctors who can stay in business won't see Medicare
patients anymore. They can't afford it.
More patients and fewer physicians will cause long lines and
rationing for our senior citizens.
Government-run Medicare already denies claims twice as much as
private insurance. But when Medicare denies coverage for a procedure--
you can't pay for it with your own money. The procedure--not the
coverage--but the procedure is denied under Medicare. That's government
rationing.
Passing the healthcare bill would only make those problems worse.
Government-run healthcare has the competence of FEMA, the efficiency
of the Post Office, and the compassion of the IRS. It is not fit for a
free people.
And that's just the way it is.
Mr. PETRI. Mr. Speaker, I rise in opposition to H.R. 3590 and H.R.
4872. I certainly agree that it is time to fix the health care system
in the United States so that all Americans have access to quality,
affordable health care. However, the path we are considering takes us
in the entirely wrong direction. And this reconciliation bill only
makes worse the Senate amendment considered by the House today.
Overall, it will break the bank because it is filled with budget
gimmicks to hide its true cost. It imposes over $500 billion in new
taxes as our fragile economy struggles towards recovery. It makes
significant cuts to Medicare, including to Medicare Advantage Plans
which will surely eliminate or reduce benefits to the 216,000
beneficiaries in Wisconsin. It gives the government unprecedented
authority over the regulation of health insurance, which will lead to
increased costs for those who currently have health insurance.
We need the right reforms to eliminate waste throughout the system
and reward high quality low-cost care. We should be choosing approaches
which give consumers incentives to use their health care dollars
wisely. Instead, we are going in the opposite direction by turning
decisions over to government bureaucrats.
Instead of getting everybody into the old, dysfunctional system and
then figuring out how to pay for it, we should emphasize advances in
efficiency so that more people will be able to afford their health
care, and the government will be better able to take care of the rest.
Unfortunately, the majority in Congress has committed us to a path
which will make the right reforms much harder to achieve.
Despite the fact that I will vote against both bills, I do want to
express my support for provisions in H.R. 4872 that make changes to the
federal student loan program. This bill eliminates the Federal Family
Education Loan (FFEL) Program and moves the origination of all federal
student loans to the Direct Loan Program. For over two decades I have
championed the Direct Loan Program as the most efficient, stable, and
cost effective federal student loan program. The change to 100 percent
direct lending marks an important step forward for students, parents,
and taxpayers.
Currently we have two federal student loan programs that provide the
exact same student loans to borrowers, and schools choose to
participate in either one or the other. The FFEL Program uses private
capital to fund student loans but receives a federal subsidy to ensure
a guaranteed rate of return. The federal government also provides a
guarantee on these loans. Thus, if a student defaults, taxpayers are on
the hook, not the private lender. The Direct Loan Program uses the
proceeds from the wholesale auction of Treasury securities to the
private sector to fund loans to students, and all servicing and bill
collection is handled by private companies operating through
performance-based contracts. The loans are delivered to students
through the same system that universities use to disburse Pell Grants.
I first became interested in student loan reform in the early 1980s
when the head of the Wisconsin higher education agency convinced me
that the FFEL program was wildly costly to the government. I introduced
the first direct loan proposal in 1983 and almost ten years later won
approval of a pilot program to test the direct loan program at hundreds
of schools nationwide, including Marquette University in my state of
Wisconsin. A year later, I successfully worked with President Clinton
to authorize the Direct Loan Program.
Over the years, there has been unanimous agreement about the
excessive costs of the FFEL program compared to the Direct Loan Program
when studied by the Congressional Budget Office (CBO), the U.S.
Government Accountability Office (GAO), and the Office of Management
and Budget (OMB) and the Treasury Department under both Presidents
Clinton and Bush. Most recently, the Congressional Budget Office
reported that a switch to all direct lending would save taxpayers $61
billion over ten years.
Besides being more expensive for the taxpayers, the FFEL program has
also been plagued by fraud and abuse which further illustrates the
drawbacks of this program for students and taxpayers. For instance,
last Congress it was found that from 2001 to 2006 nonprofit lenders
illegally claimed, according to one estimate, over $1 billion in
improper taxpayers subsidies by knowingly manipulating a loophole in
the law. And then there was the ``pay for play'' scandal in which it
was revealed that colleges and administrators received special favors,
benefits and kickbacks from lenders in exchange for steering students
to their loans.
The FFEL program has also been proven to be unreliable. In 2008,
because of the turmoil in the credit markets, Congress passed emergency
legislation to temporarily allow lenders access to Treasury funds so
they could continue to make loans. Between the Direct Loan Program and
an emergency program, the federal government now funds $8.80 of every
$10 in federal student lending activity. Over the past year, hundreds
of schools have switched to the Direct Loan Program. They report smooth
and easy transitions to the program and satisfaction with the service.
In fact, according to Student Lending Analytics, only two percent of
schools surveyed indicated they had not taken the steps necessary to
originate direct loans.
By moving to 100 percent direct lending we are not favoring
government over the private markets, there is no ``takeover'' here.
Eliminating guaranteed loans in favor of direct loans means replacing a
wasteful program with one that is more cost effective and in the
interests of students and taxpayers. So, while I must vote against this
bill due to the ill-conceived health care provisions, I strongly
support the switch to 100 percent direct lending.
Mr. HASTINGS of Florida. Mr. Speaker, we are on the brink of passing
a bill that will lay the foundation for comprehensive health care
reform. We have discussed and debated various aspects of this bill for
over a year. Now, it is time to act.
Developing and executing major reform efforts has never been easy or
pretty. Violent
[[Page H1915]]
and divisive debates waged when Congress was considering legislation
that instituted Medicare.
And yet, few would dispute that this program is essential to
delivering quality health care to some of our Nation's most vulnerable
communities--the elderly and disabled.
Like reform efforts of the past, the health care reform bill has been
met with blind criticisms and incessant fear mongering. Amazingly, some
of my colleagues talk about horrific scenarios that will result from
passing the bill and ignore the horrific conditions that people are
enduring right now. They don't speak for me. They don't speak for the
161,000 uninsured Floridians in my district, and they don't speak for
people who know that this bill is fiscally responsible and takes a
multifaceted approach to improving our health care system.
Every single day, people are forced to choose between paying their
mortgage or financing costly life-saving treatments. Every single day,
seniors are forced to choose between buying food or buying their
medication. Every single day, people are dying prematurely because they
don't have regular access to health care services. You can't tell me
that these people don't want or need health care reform.
Mr. Speaker, health care reform boils down to whether you believe
that 47 million uninsured Americans is an unfortunate but acceptable
fact, or an injustice that must be addressed.
Achieving comprehensive health care reform requires a uniquely
American approach that preserves what works and introduces new elements
that will allow us to meet 21st century needs and goals. This reform
bill does just that. I urge my colleagues to vote in support of this
historic bill and ensure that our fellow Americans have access to
affordable and high quality health care.
Mr. BACA. Mr. Speaker, I stand today in strong support of the health
care reform the American people so desperately need.
American families and small businesses--not insurance companies--
deserve control over their health care decisions.
The bill we are debating today will:
Lower insurance costs--and hold insurance companies accountable.
End denial of coverage for pre-existing conditions.
Provide coverage to 32 million uninsured Americans.
Close the Medicare Doughnut Hole--so seniors will be able to afford
the coverage they need.
Eliminate waste in our current system--and lower the deficit by $138
billion over 10 years; and $1.2 trillion over the next 20 years.
And allow young adults to stay on their parents' insurance coverage
until the age of 26.
Health care reform is an issue that affects every single American--
but is especially important to our Hispanic American community.
Forty-one percent of Hispanics over the age of 18 lack health
coverage. We must do better--and with this bill--we will.
Twenty-one percent of older Hispanics suffer from diabetes--compared
to only 14 percent of non-Hispanic whites.
The preventive care this bill provides will lower this disparity.
This truly is a historic time.
In 1935 we passed Social Security. In 1965, we passed Medicare.
Today--we pass a health care reform that will save millions of
lives--shrink our deficit, and put our nation on a path to prosperity.
We must move past the hate, the fear, and the lies that have
dominated this debate, and get the job done for the American people.
I urge my colleagues to vote for this bill and pass health care
reform that we need now and for generations to come.
Ms. BERKLEY. Mr. Speaker, I rise today in support of health care
reform.
While not perfect, this bill addresses key obstacles that continue to
plague the system. The cost of health care premiums is skyrocketing out
of control, creating an atmosphere where only insurance companies can
and will prosper and prevail. Without this reform, our individual
citizens and businesses will continue to be devastated by unsustainable
costs or barriers to coverage.
This bill would increase access for those who have been denied
insurance in the past, either because they can't afford it, have a pre-
existing condition, or have been dropped from coverage after getting
sick. It would provide financial assistance to working families to make
their health care costs affordable and it would provide businesses with
tax credits for providing health care for their employees.
In my district, this bill would extend coverage to 155,500 uninsured
residents, guarantee that 26,200 residents with pre-existing conditions
can obtain coverage, reduce the cost of uncompensated care for
hospitals and other health care providers by $74 million annually, and
allow 63,000 young adults to obtain coverage on their parents'
insurance plans.
I believe it is my duty to fight for the health, well-being and
protection of the citizens I represent. While this package does not
contain all the reforms needed, it provides a framework of very
positive first steps that will achieve a great deal for Nevada
families. There is no doubt that more must be done, but I believe this
is a step in the right direction. I urge my colleagues to vote yes on
this legislation.
Mr. PLATTS. Mr. Speaker, all members of Congress agree that the
status quo in health care is unacceptable and that we must act to make
affordable, quality health care accessible for all Americans. The
legislation before us today, however, is the wrong solution. Simply
put, it is bad public policy.
Throughout the debate on health care reform, I have emphasized that
Congress must be certain to adhere to the physician's principle of
``First, do no harm.'' Unfortunately, the Senate-passed health care
bill (H.R. 3590) and reconciliation legislation (H.R. 4278) that we are
considering today will do significant harm.
A primary focus of health care reform must be on bringing down the
rapidly rising cost of health care and health insurance. Instead, the
legislation before us today costs over $1 trillion in the first 10
years. When fully implemented, the proposed plan's costs will total
more than $200 billion per year. That's $2 trillion in additional
health care-related costs over the course of the plan's first full
decade of implementation. Once the budgetary gimmicks are stripped
away, the legislation before us will increase the overall budget
deficit dramatically.
According to the Congressional Budget Office (CBO), the proposed
legislation will do significant additional harm as well. CBO analysis
concludes that health insurance premiums in the individual market will
increase by 10-13%, Medicare will be cut by more than $500 billion,
taxes will increase by $579 billion, and millions of Americans will
ultimately be forced off private health insurance plans into
government-run plans.
Countless new taxes are included in the proposed health care
legislation. For example, new taxes would be imposed on: individuals
without health insurance; employers, whether they provide health
insurance for their employees or not; certain employer-provided health
insurance plans, more and more of them over time; medical devices, like
wheelchairs and walkers; investment income; Flexible Spending Accounts;
and health insurers and pharmaceutical companies, taxes that are likely
to be passed along to their customers.
The proposed legislation's cuts to Medicare will detrimentally impact
millions of senior citizens. For example, CBO estimates that, as
drafted, the cuts to Medicare Advantage funding will result in
approximately 4.8 million seniors losing access to such plans. Plans in
which they chose to enroll.
Mr. Speaker, the process by which we are considering these bills is
also wrong. Ordinarily, the reconciliation process is used to pass
legislation making changes in existing federal programs or taxes. The
reconciliation legislation under consideration today will make changes
to a health care bill that has yet to even be enacted. Importantly,
there is no guarantee that the reconciliation bill will be passed in
the Senate. This means that the House would be effectively trusting
that the Senate health care bill will be ``fixed'' by the
reconciliation process, even as the Senate health care bill is approved
by the House and becomes law.
The entire health care reform legislative process has been tainted by
proposals offered along the way to gain votes--like the infamous
``Cornhusker Kickback,'' as well as special provisions for other states
that have undermined confidence in the final product. Similarly, the
House leadership's initial plan of using a ``deem-and-pass''
legislative tactic--enacting the Senate bill into law without a
straight up-or-down vote--greatly diminished the American people's
trust in this legislation's provisions.
Rather than enacting the legislation before us today, Congress should
restart the process and enact common sense health care reforms that
have bipartisan support. Reforms such as small business health
insurance pools, medical malpractice liability reform, tax credits and
deductions for health care expenses, and insurance reforms addressing
the issues of pre-existing conditions and wrongful coverage termination
will better ensure access to affordable, quality health care for all
Americans, while also adhering to the physician's principle of ``First,
do no harm.''
Mr. COOPER. Mr. Speaker. I woke up this Sunday morning, said my
prayers, and finally decided that I will vote ``yes'' on health care
reform.
Having heard from tens of thousands of Middle Tennesseans on all
sides of the issue (including the flood of messages in the last few
days and hours), and having spent months studying the various bills, I
know that America must improve its health care system because it is
unsustainable. This legislation will make it better.
[[Page H1916]]
Any decision of this magnitude must be made very carefully, after
weighing every concern. We Nashvillians are proud of our outstanding
health care community that makes us ``the nation's health care industry
capital.'' Given our community's expertise, it is interesting to note
that:
Every Nashville hospital strongly supports the legislation, whether
it's St. Thomas, Vanderbilt (both University and Hospital), Centennial,
Meharry Medical School, Nashville General, Summit, Skyline, or Southern
Hills.
A majority of physicians who contacted me support the legislation
and, although the Tennessee Medical Association opposes it, the TMA's
national organization, the conservative American Medical Association,
supports it.
A majority of local nurses support the legislation, along with the
American Nurses Association.
Despite media controversy regarding abortion, the Catholic Health
Association, Catholics United, and groups representing 59,000 Catholic
Sisters support the legislation.
The largest Nashville and national senior organization, AARP,
supports the legislation.
It means a lot to me that so many local people who know so much about
health care agree with my decision.
Of course, there are plenty of people who disagree who are also very
knowledgeable about health care, and I have great respect for their
opinions. I've learned a lot from their views. Several of their
suggested improvements are already in the legislation. You may be
surprised that many of these critics want the legislation to do more,
not less. Having taught health policy at Vanderbilt's business school
for many years, I can easily point out many flaws in the legislation
myself, both substantive and procedural. I have been working hard in
Congress to eliminate those flaws. For example, yesterday we were able
to force a clear, up-or-down vote on today's legislation instead of
using the parliamentary maneuver that was favored by some in my own
party.
Let me make clear that I respect the advocacy of those who are
opposed to the legislation. They actually help me make sure that more
people in Congress do their homework and pay attention to America's
financial problems. They are strengthening our democracy with their
voices.
The bottom line is that this legislation offers the only realistic
hope that most Americans have for getting a fair deal in today's
private health insurance markets. This is not a government takeover of
those markets, but a way to encourage better private-market
competition. In the future, private insurance companies should compete
to keep us healthy, not drop us from coverage. Tens of millions of
Americans will benefit immediately from reform of these insurance
markets. Thousands of lives will literally be saved due to the greater
affordability of health insurance. This is as major a public health
accomplishment as reducing car wrecks or finding a cure for a dread
disease. One of the lives saved could be yours.
My health insurance is Tennessee Blue Cross/Blue Shield (just like I
had when I was a small businessman in Nashville) but, as a Congressman,
I am able to purchase it as part of a large pool, an exchange. I want
every American to have the same purchasing power. No matter what your
insurance company is, most Tennesseans are only one illness away, one
pink slip away, or one premium hike away from being mistreated by
current insurance practices: discrimination against pre-existing
conditions, arbitrary premium pricing, and last-minute rescission of
coverage when you need it most. This legislation will cover 32 million
hardworking, middle-class Americans who are left out in the cold by
today's insurance practices. Rival legislation only attempts to cover 3
million uninsured people, or less than 10% of the problem. America can,
and must, do better.
The financial issues involved are just as important as the coverage
issues, as I pointed out in my remarks at the President's bipartisan
summit on health care at Blair House in February. Will improved
coverage increase the deficit, either short-term or long-term? And will
this legislation start containing the explosion in health costs that
threaten our economy but do not improve our health?
Although CBO claims that the legislation will reduce deficits in the
first ten years by over $100 billion, and by over $1 trillion after
that, you don't have to believe CBO to realize that, even if you assume
zero deficit reduction, this is a huge improvement in the policymaking
of recent years. In plain English, this bill is paid for, and may even
save big money. Should these projections prove faulty, there are fail-
safe mechanisms within the legislation that, with public support,
should correct any budget problems. I proudly voted against the 2003
Medicare drug bill because it did not even attempt to pay for itself.
That one bill (which very few constituents complained about) added $600
billion to the short-term deficit and as much as $7.8 trillion in the
out years. Fiscal conservatives have much more reason to protest that
legislation than this.
There is a legitimate concern about whether the so-called ``doc fix''
should have been included in this legislation. It is not. That issue is
the result of the 1997 Balanced Budget Act formula that limits the
growth of physician reimbursement under Medicare. Since 1997, some
doctors have been able to increase their reimbursement more than
others, but all are now threatened with a 21 percent cut. This is a
$320 billion problem over the next 10 years, and a $4.2 trillion
problem in the out years. Unless this issue is resolved, it could have
more deficit impact than all of health reform. I think that we must
figure out a way to pay for the ``doc fix'' now, not add it to the
deficit. If you really care about the deficit, watch how your elected
officials vote on this key issue.
This legislation does not do enough to contain medical inflation, but
it makes a good start because it contains the largest proposed savings
in health costs in history, $600 billion over ten years. To make these
savings stick, we will all have to be vigilant because every health
care provider will immediately be asking for Congress to reduce or even
reverse those savings. For those who sincerely want Congress to have
more backbone on these issues, the answer is to support more savings
now by asking for tougher follow-on legislation. You won't achieve more
savings by encouraging Congress to slouch away from its
responsibilities today.
There are many talking heads on television who claim to want more
cuts, but their immediate plan is to do nothing. Today the official
Republican Party position is to scare seniors about Medicare and,
despite a blizzard of words, do nothing. They are behaving as badly as
the Democratic Party used to behave when scaring Social Security
recipients. If history is any guide, America only has the political
will to face up to these issues every 15 years, and, when we did
address them, Congress did not make much progress. Neither political
party will tell you that the real cost of delaying reform is roughly
$16 billion a day. That's my estimate, based on accrual accounting, of
the financial harm being done to America by a failure to resolve these
problems on a timely basis. Waiting too long to pass reform could be as
terrible a fiscal tragedy as waiting too long to treat cancer. Of
course, the pundits have no way of paying for the delay, and the fiscal
harm, that they foster. The opportunity cost of endless arguments may
even be greater than the cost of solving the problems themselves!
Opponents of today's reform also claim to have a better plan. I'd
love to see it. I am thoroughly familiar with their legislative ideas
because I have been working in a bipartisan way on these issues for
many years. They simply do not have a better plan today that could
garner more than a handful of votes, and, given their track record, are
not likely to ever present one. There is no magic wand. For example,
I've tried for many years to promote the bipartisan Healthy Americans
Act, H.R. 1321. We ended up with only a handful of cosponsors. Another
example is my friend Rep. Paul Ryan's (R-WI) interesting plan that has
made him the darling of The Wall Street Journal. His bill, H.R. 4529,
has exactly 13 cosponsors. You need at least 216 votes to get anything
accomplished. As intriguing as some of these ideas are, they are not a
solution, especially when the meter is ticking at about $16 billion a
day.
There is a lot of rhetoric about which political party is more
sincere about deficit reduction. The facts are that the last Democratic
president to have a balanced budget was Bill Clinton, just ten years
ago. The last Republican president to have a balanced budget was
Herbert Hoover, almost eighty years ago. Today's Congress has finally
passed into law important ``pay-as-you-go'' legislation that will force
Washington to start living within its means. Budget experts think that
this is the single most important step toward getting our fiscal house
in order. Blue Dog Democrats, of which I am a member, forced this
improvement in budgeting.
The President has created a bipartisan Fiscal Responsibility
Commission that will help Washington face up to its deficit problems.
The President is doing his best to implement my bipartisan legislation
on this issue, legislation that the Senate failed to pass because seven
Republican senators (who are original cosponsors) voted against their
own bill! None of these important steps toward fiscal sanity was
allowed under the previous Administration. In fact, the previous Vice
President, Dick Cheney, was famous for saying, ``Deficits don't
matter.'' He could not have been more mistaken.
Regardless of what happens to this legislation today, America cannot
afford to ignore the growing crisis in financing today's medical
system. In the future, we need to focus on these issues every year, not
every 15 years. Passage of this legislation is absolutely certain to do
that. Flaws will need to be corrected, adjustments made, new ideas
explored. I have a list ready. Just as continual advances in medicine
must be made, continual advancements
[[Page H1917]]
in delivery of medical care must be made. Both types of advancements
save lives. It is better when the private sector makes these
improvements but, when the private sector fails, then government should
help the private-sector, not run their businesses for them.
I am well aware of the fact that this is a big vote, and perhaps a
career-limiting decision. But I think most folks back home want me to
do what is right, not just what's temporarily popular. That's what my
90-year-old mother taught me. I've made tough votes before and been
proven right. Against united Republican opposition, I voted for the
1993 Clinton budget that put America on the path to the longest
economic recovery in history. Against united Republican leadership, I
voted against the 2003 Medicare drug bill that was the largest unfunded
expansion of entitlement programs in history. And against united
Republican opposition, I voted for the House health reform bill in
November of 2009 that enabled us to vote on the much better Senate
measure today.
I have the honor of representing the Hermitage District. Our greatest
hero, Andrew Jackson, said ``One man with courage is a majority.'' I
sure hope he was right.
Mr. TOWNS. Mr. Speaker, today the House of Representatives is
preparing to vote on historic health insurance reform legislation, H.R.
4872, the Health Care and Education Affordability Reconciliation Act.
We have spent more than a year debating this important bill that will
provide 32 million Americans health insurance. In my home district, New
York's 10th Congressional District, access to affordable health
insurance will make a tremendous difference in the lives of men and
women who have been burdened by the escalating costs of health care.
We can no longer wait to stem the rising tide of the uninsured and
underinsured, implement important reforms to prevent insurers from
discriminating against persons with pre-existing conditions and enact
important measures to rein in costs.
When this bill is signed into law, millions of Americans who do not
have health care today will finally walk the pathway to coverage.
American families will no longer face bankruptcy when a loved one gets
ill and seniors will finally get relief from the high cost of
prescription drugs due to our expanded coverage under Medicare Part D.
Importantly, we are doing all of this without adding one penny to the
federal deficit. In fact, this bill will reduce our federal debt by
$143 billion over the next ten years, and hundreds of billions more in
the years thereafter.
Health insurance reform is an issue I have been committed to
throughout my long congressional career. We have been close to this day
before, but this time, at long last, I am confident we will see this
legislation signed into law.
Mr. Speaker, I thank my colleagues who supported this bill.
Mr. ACKERMAN. Mr. Speaker, I rise on this historic day in strong
support of the Health Care and Education Affordability Reconciliation
Act of 2010, H.R. 4872.
Let me be perfectly clear: all Americans should have access to
affordable and quality health-care coverage. For too long, drastically
needed health-insurance reform has been delayed. I'm proud that the
overdue reform of our health-care insurance system has finally begun.
Many of us, including Members of Congress, enjoy excellent health-care
coverage. But far too many people have inadequate coverage, including
over 70,000 of my constituents who are completely uninsured. And for
those of us with coverage, the status quo is unsustainable and costly:
Without health insurance reform, the insurance premium for an average
family is expected to rise from $13,000 today to $24,000 in less than a
decade. Mr. Speaker, my constituents want reduced costs, more choices
and expanded coverage.
I support this landmark legislation because it changes the way that
insurance companies currently ration medical care: The legislation we
are about to pass would require all plans to eliminate coverage denials
because of pre-existing conditions, eliminate dropping coverage when
individuals become sick, eliminate annual and lifetime caps on how much
can be spent on care, and eliminate exorbitant out-of-pocket expenses.
Opponents of this bill would rather have the big health-insurance
companies dictate the rules. But I think all Americans deserve these
basic protections from their health-insurance plans, and these
important guarantees will improve the coverage for nearly all those who
already have insurance--even those Americans who are extremely
satisfied with their current plans.
The Act starts with what works well in today's health care system and
fixes the parts that are broken. No one has to give up the health care
they enjoy today--everyone can keep their current health plan, doctors
and hospitals. New state marketplaces called exchanges will allow
uninsured individuals to shop among a large number of private plans
with a core set of benefits. For the first time ever, American
families--even those who keep their current health insurance--will
benefit from no longer having to worry about losing health coverage
because of a new or lost job. The bill finally brings the type of
health insurance reform that Americans need and deserve.
Many opposed to comprehensive health insurance claim there are no
immediate benefits to these bills; that somehow nothing happens until
the exchanges are set up. Mr. Speaker, here are just some of the
immediate benefits that take effect this very year: small businesses
will receive tax credits for offering health insurance to their
employees; seniors who fall within the infamous Medicare prescription-
drug donut hole will receive a $250 rebate; people who have been denied
health-care coverage because of a pre-existing condition will be able
to get affordable coverage through temporary high-risk pools; children
will no longer be callously denied coverage because of a pre-existing
condition; annual limits and lifetime limits on the cost of care will
start to be prohibited; and also this year, insurance companies will no
longer be able to take away an individual's coverage because they get
sick.
Mr. Speaker, unfortunately, the previous Administration and the
former leadership of the House of Representatives never acknowledged
the moral or economic costs we pay every day for our failure to make
health coverage affordable and accessible for everyone. Today, that
ends. Today we recognize that more people with good coverage saves
lives and saves costs. Today we unequivocally state that people should
not have to go bankrupt to pay their medical bills. And today we
finally realize that no one should have to go to an emergency room just
to receive routine medical care. I am proud to be voting today to make
sure that health-care insurance reform is putting these essential
principles into action.
So, Mr. Speaker, I urge all my colleagues to support the Health Care
and Education Affordability Reconciliation Act of 2010, H.R. 4872 so
that all Americans will have access to health care.
Mr. ANDREWS. Mr. Speaker, I rise today in support of millions of
individuals throughout our country who are working for small businesses
which are in PEO arrangements. The clear objective of this legislation
is to create incentives for health care coverage and not to provide
disincentives. I would like to clarify that for purposes of the
application of section 2716 of the Public Health Service Act
(Prohibition on Discrimination in Favor of Highly Compensated
Individuals) and Internal Revenue Code section 45R (Credit for Employee
Health Insurance Expenses of Small Businesses), to any health plans
sponsored by a professional employer organization (PEO) or a PEO client
organization, the rules would be applied to each client organization
separately and eligibility for the small business tax credits would
also apply to each client organization separately, and not at the PEO
level.
Mr. KIRK. Mr. Speaker, I rise today in opposition to H.R. 3590, the
Senate Health Care bill. I strongly support reforms to lower the cost
of health insurance and cover Americans with pre-existing conditions.
That is why I authored the Medical Rights and Reform Act, H.R. 3790.
Under our centrist Reform Act, we cover Americans with pre-existing
conditions and advance three major reforms:
(1) The Medical Rights Act: Under our bill, Congress shall make no
law interfering with the personal decisions that you make with your
doctor,
(2) Lawsuit Reform: By applying the lawsuit reforms (recently
eliminated in Illinois) similar to successful California reforms, we
could reduce defensive medicine, saving over $200 billion annually, and
(3) Granting Americans Interstate Rights: Our bill grants the right
to all Americans to buy health coverage from any state in the union,
especially if you find a plan that is less expensive or more flexible
for your family or small business. This improves choice and competition
for each American.
Unfortunately, the Congressional leadership will not permit a debate
on our bill. Instead, the House will only allow one vote on the health
care bill adopted by the Senate.
Under the Senate bill, the Congress will increase spending by $1.2
trillion, including $940 billion for new subsidies, $144 billion for
new mandates, $70 billion to administer the bill and $41 billion in
unrelated spending. To attempt to pay for the bill, Congress will raise
taxes, cut Medicare and borrow a historic amount of money. To pass the
Senate, the bill also included the ``Louisiana Purchase'', ``Cornhusker
Kickback'' and ``Gatoraide'' that advantaged Louisiana, Nebraska and
Florida over the people of Illinois.
The bill imposes 12 new federal taxes, imposing over $500 billion in
new payments to the government, including over $23 billion in taxes on
the people of Illinois. Among the new taxes is a new ``Individual
Mandate Tax'' (IMT) of $2,250 per household or 2 percent of
[[Page H1918]]
household income. The bill increases the Medicare payroll tax and does
not adjust this for inflation. Therefore, like the infamous Alternative
Minimum Tax (AMT), the new Medicare tax will soon reach most middle
class families as inflation pushes more Americans into its bracket.
The bill also increases the capital gains tax. Most economists worry
that too many businesses plan for the short-term, hurting long-term
economic growth. That is why investments which are held for longer
periods of time pay a lower capital gains tax. The Senate bill reverses
this wise policy by imposing a new 3.8 percent tax on capital gains,
raising the rate from 15 percent to 23.8 percent by 2013.
Both Americans for Tax Reform and the Heritage Foundation estimated
that the new taxes and Medicare cuts in the bill would cost over
600,000 job opportunities per year or an estimated 26,042 fewer
Illinois jobs. The bill also has a number of budget gimmicks to hide
spending. Once the Social Security Trust Fund, long-term health care
and student loan gimmicks are removed, the bill adds $755 billion to
the federal deficit or $2,460 in new debt for each man, woman, and
child.
Here is a look at the estimated national job losses under the bill:
------------------------------------------------------------------------
Sector Jobs
------------------------------------------------------------------------
Agriculture, forestry, fishing and hunting.................. -5,441
Mining...................................................... -5,478
Construction................................................ -43,316
Manufacturing............................................... -105,229
Wholesale trade............................................. -47,663
Retail trade................................................ -84,339
Transportation and warehousing.............................. -36,806
Utilities................................................... -5,271
Information................................................. -26,342
Financial Activities........................................ -77,269
Professional and business services.......................... -132,596
Educational services........................................ -32,102
Leisure and hospitality..................................... -49,682
Other services.............................................. -46,564
------------------------------------------------------------------------
Total................................................... -698,098
------------------------------------------------------------------------
Half of all people employed in Illinois work in a small business and
over 80 percent of job losses during this Great Recession have been
from small business employers. Nevertheless, this legislation requires
the federal government to levy a new $52 billion tax on small
businesses, even though unemployment now tops 12 percent in Illinois.
The bill begins a new $2,000 tax on small business with over 50
employees. Over 21,600 small businesses in Illinois could be subject to
this new tax. This tax applies to part-time as well as full-time
workers. The follow-up Reconciliation Bill also includes an
unprecedented extension of the Medicare tax to all non-wage income.
The legislation stands for the principle that we should cut senior
health care under Medicare to fund a new entitlement spending program.
Over 40 million seniors depend on Medicare for their health care. Under
the Senate bill, the federal government would cut over $500 billion
from Medicare. This includes cutting over $200 billion from Medicare
Advantage, cancelling the Medicare choice of over 120,000 Illinois
seniors.
Here is a summary of the Medicare cuts:
------------------------------------------------------------------------
------------------------------------------------------------------------
Medicare Advantage........................ $202 billion.
Home Health............................... 39 billion.
Medicare Part B........................... 25 billion.
Hospital DSH Payments..................... 25 billion.
Medicare Part D........................... 10 billion.
Medical Imaging........................... 1 billion.
Preventative Services..................... 700 million.
Durable Medical Equipment................. 1 billion.
Power-Driven Wheelchairs.................. 800 million.
Hospice................................... 100 million.
Medicare Improvement Fund................. 20 billion.
Medigap................................... 100 million.
------------------------------------------------------------------------
Total................................. $523 billion.
------------------------------------------------------------------------
While the American people overwhelmingly want to lower health
insurance costs, the bill increases costs because it requires Americans
to buy health insurance that include new mandates for coverage.
According to the Administration, individual insurance premiums will
increase by 10 percent for over 600,000 people in Illinois. On average,
Illinois individuals currently pay $2,499 annually for insurance. Under
the bill, costs will go up at least $150 a month to a level of $4,299
annually.
On March 4, the Chicago Tribune reported that for ``more than half-
million consumers in individual health plans, base rates will go up
from 8.5 percent to more than 60 percent.'' The non-partisan
Congressional Budget Office reported that the bill's provisions that
double the tax on health insurers, drug makers and medical devices will
all be passed on to patients in the form of higher health costs and
rising insurance premiums.
Under the federal Medicaid program for the poor, states must pay half
of all costs. As you know, the State of Illinois has one of the highest
deficits of any state, totaling over $12 billion. Spending on the
Illinois Medicaid program rose 65 percent from $8 billion in 2001 to
$13 billion in 2008 to now cover 2.4 million people. Under the Senate
Health Care bill, Illinois would have to cover an additional 400,000
people, adding an additional $1 billion to the state's deficit over
five years.
Health care under Medicaid is already deteriorating. Over 9,000
doctors in Illinois refuse to accept Medicaid patients (28 percent
nationwide), in part because it takes Illinois over 100 days to pay for
services.
About the only jobs created by the legislation would be at the IRS.
According to the nonpartisan Congressional Budget Office, the IRS would
need to hire over 16,000 people--over 700 just in Illinois--to audit
the American people and impose the new taxes and mandates of the bill.
New IRS agents would verify if you have acceptable authority, fine you
up to 2 percent of your income for failure to prove that you have
purchased ``minimum essential coverage,'' confiscate your tax refund
and conduct audits. Under the bill, nearly half of the new individual
mandate taxes will be paid by Americans earning less than $66,150 for a
family of four.
I will vote against this legislation because it costs Illinois jobs,
raises taxes and deepens the debt our children must one day pay. I wish
that we could adopt a more modest set of reforms that do not have such
harsh consequences for our economy.
In the coming days, I will outline policies and legislation that will
reduce spending, lower the debt and prevent new taxes on the American
people. While we did not prevail in this contest, I will continue to
work and ensure a strong economy and bright future for every Illinois
citizen.
Mr. GRIJALVA. Mr. Speaker, after a long battle for this Nation's
health care reform, my decision to vote in favor of this bill was
ultimately made, not by myself, but by the people I represent.
This bill is a beginning to the end of an abusive system:
It is a beginning to provide the people of our great Nation access
the most basic health care services;
It is a beginning to stop insurance companies from reaping benefits
at the cost of the sick, injured, poor and dying people in our Nation;
It is a beginning to making our health care system one that we can be
proud of--
One that includes everyone regardless of their social status;
One that treats people equal regardless of their age, race or gender;
One that makes sure our children are treated properly and that our
parents will be provided for in the future; and
It finally provides reauthorization of Indian Health Care.
Every day I am flooded by groups, businesses and individuals that can
no longer bear the abuses from our current health care system. I want
to share of few of their reasons for supporting this bill:
The National Committee to Preserve Social Security and Medicare
states:
The bill preserves and improves Medicare for current and
future beneficiaries. Because of our strong commitment to
Medicare, we support the health reform currently before
Congress. Indeed, we consider it to be vital for preserving
and protecting Medicare. On behalf of the seniors you
represent, we ask that you commit to supporting health reform
as well.
Catholic Sisters for Healthcare Reform states:
We have witnessed firsthand the impact of our national
health care crisis, particularly its impact on women,
children and people who are poor. We see the toll on families
who have delayed seeking care due to a lack of health
insurance coverage or lack of funds with which to pay high
deductibles and co-pays. We have counseled and prayed with
men, women and children who have been denied health care
coverage by insurance companies. We have witnessed early and
avoidable deaths because of delayed medical treatment.
American Nurses Association states:
We understand the cost of inaction--our patients can no
longer afford to wait. The uninsured and underinsured
continue to delay or forgo much-needed care; they continue to
arrive in the emergency rooms across the country for
conditions that could have been easily prevented with access
to primary care--we are all paying a high price for inaction.
My dear friend, Karen, from the National Breast Cancer Coalition came
to me and poured her heart out on behalf of the millions of women
battling cancer, this vote is for you. The National Breast Cancer
Coalition states:
For women who are battling breast cancer, health care
reform will mean accessing potentially life-saving treatment
and not losing their health insurance coverage if they lose
their job. For their families, it means not being driven into
bankruptcy when the person they love has been diagnosed with
breast cancer, must contend with a recurrence of the disease,
or struggle with equally life threatening complications. For
the tens of thousands of women who will be diagnosed with
breast cancer today and in the future, enacting health care
reform will mean being able to focus their energy on battling
the disease, not fighting with their insurance company. We
cannot delay any longer.
United States Hispanic Chamber of Commerce states:
[[Page H1919]]
As business owners, we know well the concept of opportunity
cost. The rate of premium growth has become such a burden to
our businesses that we are required to support this
compromise rather than see premiums double, or triple, once
again as they have done this decade. As organizations that
believe in free market solutions, this decision was not taken
lightly. But, the fact remains that the small business
components in this compromise bill will provide real relief--
a small business exchange that pools risk while respecting
the free market and tax credits to incentivize those
businesses that are just within reach of providing health
care to their workers.
While these groups and the American people understand this bill is
the beginning of reforming our system, I can assure you it is not the
end.
I will continue to fight for a public entity to be part of our
system.
I will continue to fight for immigrants to be treated fairly in our
Nation, and I will argue the grave economic impacts of leaving these
people out of our system.
I will continue to fight for stricter control of the pharmaceutical
companies to force them to negotiate prices instead of dictating them.
And above all I will not stop, I will continue to push to make our
system more efficient and more equitable--this is only the beginning.
I would like to end with a quote from my dear friend that we lost
during the mist of this battle, who I feel has been our guiding light.
Ted Kennedy said:
The battle to achieve Medicare for All will not be easy.
Powerful interests will strongly oppose it, because they
profit immensely from the status quo. Right wing forces will
unleash false attack ads ranting against socialized medicine
and government-run health care.
Ted--we will not give up--this is the beginning.
Mr. FRELINGHUYSEN. Mr. Speaker, at the outset, let me be very clear:
I support health care reform. I just do not support Speaker Nancy
Pelosi's version of health care reform.
With respect to controlling costs for New Jersey's families, changing
insurance company practices and making coverage more available to more
Americans, the status quo is simply unacceptable. We can, and we must,
do better, but not at the expense of millions of American families who
are worried about a government takeover of their health care decisions!
With that said, the health care package before the House today is
wrong on both process and policy.
On process, the American people know instinctively that a change as
historic as this will only be successful with full engagement of the
American people and bipartisan support in Congress. However, from the
beginning, Speaker Nancy Pelosi and Senate Majority Leader Harry Reid
adopted a `go-it-alone' strategy and refused to consider Republican
ideas in any significant way. Indeed, the Majority today is even
refusing to listen to the very valid concerns of the American people.
In addition, this legislation, and all the versions that preceded it,
were drafted behind closed doors at the White House or in Capitol
backrooms, with no transparency whatsoever as to which organizations
were participating and benefitting! In fact, the Majority had to be
`shamed' into releasing the contents of the bill 72 hours before a vote
to allow Republicans and the American people to review its contents.
To add insult to injury, the President and Speaker Pelosi decided to
use the budget 'reconciliation' process solely to deny the Senate
Minority the ability to use its traditional practice of the filibuster
to block passage of harmful legislation such as this.
Madame Speaker, the process the Majority has used is shameful, but
the policy they seek to impose is downright harmful.
Once again, I state without hesitation that I support health reform.
However, I cannot support this proposal.
First, this package contains over $523 billion in job-killing, higher
taxes. I cannot think of a worse time to tax families and small
businessmen and women than in the middle of a serious recession.
The American people need to understand the destructive nature of this
bill: $17 billion in new taxes on Americans who do not obey the bill's
requirement that individuals must buy health insurance whether they
want to or not, and $52 billion in new taxes on employers that do not
provide health coverage deemed ``acceptable'' or ``affordable'' by
Washington-based government bureaucrats. This provision alone may force
the IRS to hire another 16,000 agents and auditors to enforce
compliance with the new law.
In addition, the bill contains new taxes on capital gains, dividends
and interest that will further stifle economic growth and job creation.
The Medicare tax on capital gains, dividends, and other investment
income gets bigger, magnifying the destructive power of the tax. The
bill increases the tax from 2.9 percent to 3.8 percent and for the
first time, this tax will be extended beyond wages to include interest,
dividends, capital gains, annuities, royalties, home sales and rents.
This new tax will be particularly damaging to New Jersey's seniors,
many of whom depend on such income to survive.
Second, this package contains over $569 billion in total cuts to
Medicare.
These reductions include $202.3 billion from seniors' Medicare health
plans, including massive cuts targeting the extra benefits and reduced
cost-sharing seniors receive through Medicare Advantage. 148,000
seniors in New Jersey, including over 35,000 in my Congressional
District enjoy the benefits of this innovative program. The
Congressional Budget Office predicts that three million seniors
nationwide currently receiving health benefits through these Medicare
plans will be dropped.
But the Medicare cuts go deeper. The bill slashes $156 billion from
hospitals, including long-term care hospitals, skilled nursing
facilities, Ambulatory Surgical Centers, hospice, ambulances, dialysis
facilities, labs and durable medical equipment (DME) suppliers.
The package also contains $40 billion in cuts to home health
reimbursements and $22 billion in additional cuts to hospitals by
slashing reimbursements designed to assist hospitals that serve low-
income patients. In addition, $65.7 billion in money will be taken from
seniors in the form of higher premiums.
My colleagues, I am also shocked that the Majority has not protected
our men and women in uniform, military retirees and veterans who could
be affected by the new law. The Senate-passed health care bill omitted
protections for military health plans that were included in the House
bill.
Specifically, the Senate language does not appear to give the
Department of Veterans' Affairs (VA) health care system specific
protection from interference by other government agencies administering
the various authorities contained in the massive bill, as it pertains
to ``minimum essential coverage.''
Further, the final bills would leave it up to bureaucrats at the
Department of the Treasury to determine whether TRICARE meets the
minimum standards under the bill's individual health insurance mandate.
If that bureaucrat decides against TRICARE, service members and their
families would have to buy some other health coverage or pay a penalty.
Our men and women in uniform, and our veterans, have earned the best
health care available. They need to know that they will continue to
receive this same level of care. It is truly regrettable that, in a
bill stuffed with `backroom' deals and special `arrangements', this
group of American heroes is denied the consideration they earn on the
battlefield each and every day.
Mr. Speaker, this bill is also notable for what it does not contain.
There is no medical lawsuit reform. It fails to promote portability of
coverage. It does not allow insurance companies to sell their policies
across state lines. It fails to recognize the value of Association
Health Plans, which permit small businesses to pool their risk in order
to secure lower insurance rates. The bill does not expand Health
Savings Accounts which millions of families use to provide protection
against catastrophic illness or injury. The package also does very
little to enhance medical training for doctors, nurses and technicians.
If we are going to expand coverage for tens of millions of Americans,
we need to increase graduation rates in these critical medical
professions.
I would also add that this bill completely ignores the ongoing crisis
in Medicare reimbursement rates for doctors. My colleagues, the
question is not whether you can choose your doctor under the Pelosi
health care proposal, but whether your doctor will choose you! Many
doctors in New Jersey are already questioning their participation in
the Medicare program, putting in greater jeopardy our seniors' access
to care. Does the Majority actually believe that the pending 22-percent
reimbursement reduction will not cause more doctors to `opt out' of
Medicare?
Mr. Speaker, I end this statement where I started: I support health
care reform. The status quo is unacceptable and I would welcome the
opportunity to work with anyone who will work with me to draft and pass
single, individual bills that promote portability of coverage, allow
individuals to buy health care across state lines, cover people with
preexisting conditions, improve access to Health Savings Accounts, and
enact `junk lawsuit' reform, among other actions to bring down the cost
of coverage for New Jersey families and businesses.
We can do better than this process and this package. America's future
economic and security freedoms depend on it.
Mr. TAYLOR. Mr. Speaker, I voted against H.R. 3962, the Affordable
Health Care for America Act, on November 7, 2009 and I will continue to
oppose this legislation in the House. The House passed the bill by a
vote of 220-215. During House consideration, I voted for the Stupak
amendment, which prohibits federal funds from paying for abortions
[[Page H1920]]
or from subsidizing health insurance plans that would cover abortions.
The House passed the Stupak amendment by a vote of 240-194.
Taxpayers cannot afford a new federal health insurance program. The
government already provides Medicare, Medicaid, and other programs to
provide medical care for senior citizens, people with disabilities, and
others who have substantial medical needs. Our nation also has an
obligation to provide medical coverage for veterans, active-duty
military and their dependents, National Guard and Reserve personnel,
and military retirees. With the national debt in excess of $12 trillion
and projected to grow far into the future, I believe that Congress
should focus on fulfilling the promises that have already been made
rather than make new promises that we cannot afford.
There are several ways to make health care more efficient without
increasing costs and without creating a whole new government program.
I strongly support efforts to allow the government to use their
purchasing power to negotiate directly with drug manufacturers when
buying prescription drugs for beneficiaries enrolled in the Medicare
Part D Program. Negotiating prices with insurance companies would help
to ensure that taxpayers are paying the best available price and that
tax dollars are spent wisely without reducing coverage or affecting the
individuals enrolled in Medicare Part D. In 2008, the government spent
about $49 billion on Medicare Part D drugs. If the government could
save even 10% by negotiating directly with drug companies, taxpayers
would save nearly $4.9 billion.
The government should purchase generic drugs instead of more
expensive alternatives, unless the prescribing physician says that a
name brand drug is medically necessary. On average, generic drugs cost
1/10th of the cost of their name brand equivalent.
I am a cosponsor of H.R. 1583, legislation to repeal the insurance
industry's antitrust exemption. The health care bill that passed the
House included a repeal of antitrust laws only for the health care
industry. While this is important, I firmly believe that repealing
antitrust laws from the entire insurance industry would force insurers
to compete with one another in a competitive market on the basis of
price, service, and value. I strongly supported the bill that passed in
the House which repealed the exemption of antitrust laws for the health
care insurance industry.
I am also in favor of proposals that would allow individuals to
continue to be covered under their parents' insurance plan until they
reach the age of 27.
I would like to remind you that I do not support creating a whole new
health care program, but I do support smaller reforms to make the
current system more effective for taxpayers and consumers. Again, I
voted against the health care bill that passed the House, and I will
oppose this bill.
Mr. MORAN of Virginia. Mr. Speaker, today we will define who we are--
as Americans, and as Democrats or Republicans.
No Republican will vote for this bill because they say they want a
smaller government, lower taxes, and less spending.
Democrats, on the other hand, believe that America's government can
be fiscally responsible and also play an essential role in helping
America achieve its true greatness.
We know that America is a lesser Nation when we have to pay twice
what other countries citizens' pay for health care, while we live
shorter and less healthy lives; We are a lesser nation when millions of
America's families lose their homes and life savings because a loved
one gets seriously sick.
We know that we can reduce the suffering of our people, while
lengthening and bettering their lives. And because we know this, we
have a responsibility to change it.
As with Social Security and Medicare and Civil Rights legislation, it
is now time for another step in our historic progress toward greatness.
That's why we chose public service and why we, as Democrats, will pass
this bill today.
The SPEAKER pro tempore. Under the rule, all time for debate has
expired.
Mr. SPRATT. Mr. Speaker, pursuant to House Resolution 1203, I call up
the bill (H.R. 3590) to amend the Internal Revenue Code of 1986 to
modify the first-time homebuyers credit in the case of members of the
Armed Forces and certain other Federal employees, and for other
purposes, with the Senate amendments thereto, and I have a motion at
the desk.
The Clerk read the title of the bill.
The SPEAKER pro tempore. The Clerk will designate the Senate
amendments.
The text of the Senate amendments is as follows:
Senate amendments:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Patient
Protection and Affordable Care Act''.
(b) Table of Contents.--The table of contents of this Act
is as follows:
Sec. 1. Short title; table of contents.
TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
Subtitle A--Immediate Improvements in Health Care Coverage for All
Americans
Sec. 1001. Amendments to the Public Health Service Act.
``PART A--Individual and Group Market Reforms
``subpart ii--improving coverage
``Sec. 2711. No lifetime or annual limits.
``Sec. 2712. Prohibition on rescissions.
``Sec. 2713. Coverage of preventive health services.
``Sec. 2714. Extension of dependent coverage.
``Sec. 2715. Development and utilization of uniform explanation of
coverage documents and standardized definitions.
``Sec. 2716. Prohibition of discrimination based on salary.
``Sec. 2717. Ensuring the quality of care.
``Sec. 2718. Bringing down the cost of health care coverage.
``Sec. 2719. Appeals process.
Sec. 1002. Health insurance consumer information.
Sec. 1003. Ensuring that consumers get value for their dollars.
Sec. 1004. Effective dates.
Subtitle B--Immediate Actions to Preserve and Expand Coverage
Sec. 1101. Immediate access to insurance for uninsured individuals with
a preexisting condition.
Sec. 1102. Reinsurance for early retirees.
Sec. 1103. Immediate information that allows consumers to identify
affordable coverage options.
Sec. 1104. Administrative simplification.
Sec. 1105. Effective date.
Subtitle C--Quality Health Insurance Coverage for All Americans
PART I--Health Insurance Market Reforms
Sec. 1201. Amendment to the Public Health Service Act.
``subpart i--general reform
``Sec. 2704. Prohibition of preexisting condition exclusions or other
discrimination based on health status.
``Sec. 2701. Fair health insurance premiums.
``Sec. 2702. Guaranteed availability of coverage.
``Sec. 2703. Guaranteed renewability of coverage.
``Sec. 2705. Prohibiting discrimination against individual participants
and beneficiaries based on health status.
``Sec. 2706. Non-discrimination in health care.
``Sec. 2707. Comprehensive health insurance coverage.
``Sec. 2708. Prohibition on excessive waiting periods.
PART II--Other Provisions
Sec. 1251. Preservation of right to maintain existing coverage.
Sec. 1252. Rating reforms must apply uniformly to all health insurance
issuers and group health plans.
Sec. 1253. Effective dates.
Subtitle D--Available Coverage Choices for All Americans
PART I--Establishment of Qualified Health Plans
Sec. 1301. Qualified health plan defined.
Sec. 1302. Essential health benefits requirements.
Sec. 1303. Special rules.
Sec. 1304. Related definitions.
PART II--Consumer Choices and Insurance Competition Through Health
Benefit Exchanges
Sec. 1311. Affordable choices of health benefit plans.
Sec. 1312. Consumer choice.
Sec. 1313. Financial integrity.
PART III--State Flexibility Relating to Exchanges
Sec. 1321. State flexibility in operation and enforcement of Exchanges
and related requirements.
Sec. 1322. Federal program to assist establishment and operation of
nonprofit, member-run health insurance issuers.
Sec. 1323. Community health insurance option.
Sec. 1324. Level playing field.
PART IV--State Flexibility to Establish Alternative Programs
Sec. 1331. State flexibility to establish basic health programs for
low-income individuals not eligible for Medicaid.
Sec. 1332. Waiver for State innovation.
Sec. 1333. Provisions relating to offering of plans in more than one
State.
PART V--Reinsurance and Risk Adjustment
Sec. 1341. Transitional reinsurance program for individual and small
group markets in each State.
Sec. 1342. Establishment of risk corridors for plans in individual and
small group markets.
Sec. 1343. Risk adjustment.
[[Page H1921]]
Subtitle E--Affordable Coverage Choices for All Americans
PART I--Premium Tax Credits and Cost-sharing Reductions
subpart a--premium tax credits and cost-sharing reductions
Sec. 1401. Refundable tax credit providing premium assistance for
coverage under a qualified health plan.
Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified
health plans.
subpart b--eligibility determinations
Sec. 1411. Procedures for determining eligibility for Exchange
participation, premium tax credits and reduced cost-
sharing, and individual responsibility exemptions.
Sec. 1412. Advance determination and payment of premium tax credits and
cost-sharing reductions.
Sec. 1413. Streamlining of procedures for enrollment through an
exchange and State Medicaid, CHIP, and health subsidy
programs.
Sec. 1414. Disclosures to carry out eligibility requirements for
certain programs.
Sec. 1415. Premium tax credit and cost-sharing reduction payments
disregarded for Federal and Federally-assisted programs.
PART II--Small Business Tax Credit
Sec. 1421. Credit for employee health insurance expenses of small
businesses.
Subtitle F--Shared Responsibility for Health Care
PART I--Individual Responsibility
Sec. 1501. Requirement to maintain minimum essential coverage.
Sec. 1502. Reporting of health insurance coverage.
PART II--Employer Responsibilities
Sec. 1511. Automatic enrollment for employees of large employers.
Sec. 1512. Employer requirement to inform employees of coverage
options.
Sec. 1513. Shared responsibility for employers.
Sec. 1514. Reporting of employer health insurance coverage.
Sec. 1515. Offering of Exchange-participating qualified health plans
through cafeteria plans.
Subtitle G--Miscellaneous Provisions
Sec. 1551. Definitions.
Sec. 1552. Transparency in government.
Sec. 1553. Prohibition against discrimination on assisted suicide.
Sec. 1554. Access to therapies.
Sec. 1555. Freedom not to participate in Federal health insurance
programs.
Sec. 1556. Equity for certain eligible survivors.
Sec. 1557. Nondiscrimination.
Sec. 1558. Protections for employees.
Sec. 1559. Oversight.
Sec. 1560. Rules of construction.
Sec. 1561. Health information technology enrollment standards and
protocols.
Sec. 1562. Conforming amendments.
Sec. 1563. Sense of the Senate promoting fiscal responsibility.
TITLE II--ROLE OF PUBLIC PROGRAMS
Subtitle A--Improved Access to Medicaid
Sec. 2001. Medicaid coverage for the lowest income populations.
Sec. 2002. Income eligibility for nonelderly determined using modified
gross income.
Sec. 2003. Requirement to offer premium assistance for employer-
sponsored insurance.
Sec. 2004. Medicaid coverage for former foster care children.
Sec. 2005. Payments to territories.
Sec. 2006. Special adjustment to FMAP determination for certain States
recovering from a major disaster.
Sec. 2007. Medicaid Improvement Fund rescission.
Subtitle B--Enhanced Support for the Children's Health Insurance
Program
Sec. 2101. Additional federal financial participation for CHIP.
Sec. 2102. Technical corrections.
Subtitle C--Medicaid and CHIP Enrollment Simplification
Sec. 2201. Enrollment Simplification and coordination with State Health
Insurance Exchanges.
Sec. 2202. Permitting hospitals to make presumptive eligibility
determinations for all Medicaid eligible populations.
Subtitle D--Improvements to Medicaid Services
Sec. 2301. Coverage for freestanding birth center services.
Sec. 2302. Concurrent care for children.
Sec. 2303. State eligibility option for family planning services.
Sec. 2304. Clarification of definition of medical assistance.
Subtitle E--New Options for States to Provide Long-Term Services and
Supports
Sec. 2401. Community First Choice Option.
Sec. 2402. Removal of barriers to providing home and community-based
services.
Sec. 2403. Money Follows the Person Rebalancing Demonstration.
Sec. 2404. Protection for recipients of home and community-based
services against spousal impoverishment.
Sec. 2405. Funding to expand State Aging and Disability Resource
Centers.
Sec. 2406. Sense of the Senate regarding long-term care.
Subtitle F--Medicaid Prescription Drug Coverage
Sec. 2501. Prescription drug rebates.
Sec. 2502. Elimination of exclusion of coverage of certain drugs.
Sec. 2503. Providing adequate pharmacy reimbursement.
Subtitle G--Medicaid Disproportionate Share Hospital (DSH) Payments
Sec. 2551. Disproportionate share hospital payments.
Subtitle H--Improved Coordination for Dual Eligible Beneficiaries
Sec. 2601. 5-year period for demonstration projects.
Sec. 2602. Providing Federal coverage and payment coordination for dual
eligible beneficiaries.
Subtitle I--Improving the Quality of Medicaid for Patients and
Providers
Sec. 2701. Adult health quality measures.
Sec. 2702. Payment Adjustment for Health Care-Acquired Conditions.
Sec. 2703. State option to provide health homes for enrollees with
chronic conditions.
Sec. 2704. Demonstration project to evaluate integrated care around a
hospitalization.
Sec. 2705. Medicaid Global Payment System Demonstration Project.
Sec. 2706. Pediatric Accountable Care Organization Demonstration
Project.
Sec. 2707. Medicaid emergency psychiatric demonstration project.
Subtitle J--Improvements to the Medicaid and CHIP Payment and Access
Commission (MACPAC)
Sec. 2801. MACPAC assessment of policies affecting all Medicaid
beneficiaries.
Subtitle K--Protections for American Indians and Alaska Natives
Sec. 2901. Special rules relating to Indians.
Sec. 2902. Elimination of sunset for reimbursement for all medicare
part B services furnished by certain indian hospitals and
clinics.
Subtitle L--Maternal and Child Health Services
Sec. 2951. Maternal, infant, and early childhood home visiting
programs.
Sec. 2952. Support, education, and research for postpartum depression.
Sec. 2953. Personal responsibility education.
Sec. 2954. Restoration of funding for abstinence education.
Sec. 2955. Inclusion of information about the importance of having a
health care power of attorney in transition planning for
children aging out of foster care and independent living
programs.
TITLE III--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE
Subtitle A--Transforming the Health Care Delivery System
PART I--Linking Payment to Quality Outcomes Under the Medicare Program
Sec. 3001. Hospital Value-Based purchasing program.
Sec. 3002. Improvements to the physician quality reporting system.
Sec. 3003. Improvements to the physician feedback program.
Sec. 3004. Quality reporting for long-term care hospitals, inpatient
rehabilitation hospitals, and hospice programs.
Sec. 3005. Quality reporting for PPS-exempt cancer hospitals.
Sec. 3006. Plans for a Value-Based purchasing program for skilled
nursing facilities and home health agencies.
Sec. 3007. Value-based payment modifier under the physician fee
schedule.
Sec. 3008. Payment adjustment for conditions acquired in hospitals.
PART II--National Strategy to Improve Health Care Quality
Sec. 3011. National strategy.
Sec. 3012. Interagency Working Group on Health Care Quality.
Sec. 3013. Quality measure development.
Sec. 3014. Quality measurement.
Sec. 3015. Data collection; public reporting.
PART III--Encouraging Development of New Patient Care Models
Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation
within CMS.
Sec. 3022. Medicare shared savings program.
Sec. 3023. National pilot program on payment bundling.
Sec. 3024. Independence at home demonstration program.
Sec. 3025. Hospital readmissions reduction program.
Sec. 3026. Community-Based Care Transitions Program.
Sec. 3027. Extension of gainsharing demonstration.
Subtitle B--Improving Medicare for Patients and Providers
PART I--Ensuring Beneficiary Access to Physician Care and Other
Services
Sec. 3101. Increase in the physician payment update.
Sec. 3102. Extension of the work geographic index floor and revisions
to the practice expense geographic adjustment under the
Medicare physician fee schedule.
Sec. 3103. Extension of exceptions process for Medicare therapy caps.
Sec. 3104. Extension of payment for technical component of certain
physician pathology services.
Sec. 3105. Extension of ambulance add-ons.
[[Page H1922]]
Sec. 3106. Extension of certain payment rules for long-term care
hospital services and of moratorium on the establishment
of certain hospitals and facilities.
Sec. 3107. Extension of physician fee schedule mental health add-on.
Sec. 3108. Permitting physician assistants to order post-Hospital
extended care services.
Sec. 3109. Exemption of certain pharmacies from accreditation
requirements.
Sec. 3110. Part B special enrollment period for disabled TRICARE
beneficiaries.
Sec. 3111. Payment for bone density tests.
Sec. 3112. Revision to the Medicare Improvement Fund.
Sec. 3113. Treatment of certain complex diagnostic laboratory tests.
Sec. 3114. Improved access for certified nurse-midwife services.
PART II--Rural Protections
Sec. 3121. Extension of outpatient hold harmless provision.
Sec. 3122. Extension of Medicare reasonable costs payments for certain
clinical diagnostic laboratory tests furnished to
hospital patients in certain rural areas.
Sec. 3123. Extension of the Rural Community Hospital Demonstration
Program.
Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program.
Sec. 3125. Temporary improvements to the Medicare inpatient hospital
payment adjustment for low-volume hospitals.
Sec. 3126. Improvements to the demonstration project on community
health integration models in certain rural counties.
Sec. 3127. MedPAC study on adequacy of Medicare payments for health
care providers serving in rural areas.
Sec. 3128. Technical correction related to critical access hospital
services.
Sec. 3129. Extension of and revisions to Medicare rural hospital
flexibility program.
PART III--Improving Payment Accuracy
Sec. 3131. Payment adjustments for home health care.
Sec. 3132. Hospice reform.
Sec. 3133. Improvement to medicare disproportionate share hospital
(DSH) payments.
Sec. 3134. Misvalued codes under the physician fee schedule.
Sec. 3135. Modification of equipment utilization factor for advanced
imaging services.
Sec. 3136. Revision of payment for power-driven wheelchairs.
Sec. 3137. Hospital wage index improvement.
Sec. 3138. Treatment of certain cancer hospitals.
Sec. 3139. Payment for biosimilar biological products.
Sec. 3140. Medicare hospice concurrent care demonstration program.
Sec. 3141. Application of budget neutrality on a national basis in the
calculation of the Medicare hospital wage index floor.
Sec. 3142. HHS study on urban Medicare-dependent hospitals.
Sec. 3143. Protecting home health benefits.
Subtitle C--Provisions Relating to Part C
Sec. 3201. Medicare Advantage payment.
Sec. 3202. Benefit protection and simplification.
Sec. 3203. Application of coding intensity adjustment during MA payment
transition.
Sec. 3204. Simplification of annual beneficiary election periods.
Sec. 3205. Extension for specialized MA plans for special needs
individuals.
Sec. 3206. Extension of reasonable cost contracts.
Sec. 3207. Technical correction to MA private fee-for-service plans.
Sec. 3208. Making senior housing facility demonstration permanent.
Sec. 3209. Authority to deny plan bids.
Sec. 3210. Development of new standards for certain Medigap plans.
Subtitle D--Medicare Part D Improvements for Prescription Drug Plans
and MA-PD Plans
Sec. 3301. Medicare coverage gap discount program.
Sec. 3302. Improvement in determination of Medicare part D low-income
benchmark premium.
Sec. 3303. Voluntary de minimis policy for subsidy eligible individuals
under prescription drug plans and MA-PD plans.
Sec. 3304. Special rule for widows and widowers regarding eligibility
for low-income assistance.
Sec. 3305. Improved information for subsidy eligible individuals
reassigned to prescription drug plans and MA-PD plans.
Sec. 3306. Funding outreach and assistance for low-income programs.
Sec. 3307. Improving formulary requirements for prescription drug plans
and MA-PD plans with respect to certain categories or
classes of drugs.
Sec. 3308. Reducing part D premium subsidy for high-income
beneficiaries.
Sec. 3309. Elimination of cost sharing for certain dual eligible
individuals.
Sec. 3310. Reducing wasteful dispensing of outpatient prescription
drugs in long-term care facilities under prescription
drug plans and MA-PD plans.
Sec. 3311. Improved Medicare prescription drug plan and MA-PD plan
complaint system.
Sec. 3312. Uniform exceptions and appeals process for prescription drug
plans and MA-PD plans.
Sec. 3313. Office of the Inspector General studies and reports.
Sec. 3314. Including costs incurred by AIDS drug assistance programs
and Indian Health Service in providing prescription drugs
toward the annual out-of-pocket threshold under part D.
Sec. 3315. Immediate reduction in coverage gap in 2010.
Subtitle E--Ensuring Medicare Sustainability
Sec. 3401. Revision of certain market basket updates and incorporation
of productivity improvements into market basket updates
that do not already incorporate such improvements.
Sec. 3402. Temporary adjustment to the calculation of part B premiums.
Sec. 3403. Independent Medicare Advisory Board.
Subtitle F--Health Care Quality Improvements
Sec. 3501. Health care delivery system research; Quality improvement
technical assistance.
Sec. 3502. Establishing community health teams to support the patient-
centered medical home.
Sec. 3503. Medication management services in treatment of chronic
disease.
Sec. 3504. Design and implementation of regionalized systems for
emergency care.
Sec. 3505. Trauma care centers and service availability.
Sec. 3506. Program to facilitate shared decisionmaking.
Sec. 3507. Presentation of prescription drug benefit and risk
information.
Sec. 3508. Demonstration program to integrate quality improvement and
patient safety training into clinical education of health
professionals.
Sec. 3509. Improving women's health.
Sec. 3510. Patient navigator program.
Sec. 3511. Authorization of appropriations.
Subtitle G--Protecting and Improving Guaranteed Medicare Benefits
Sec. 3601. Protecting and improving guaranteed Medicare benefits.
Sec. 3602. No cuts in guaranteed benefits.
TITLE IV--PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH
Subtitle A--Modernizing Disease Prevention and Public Health Systems
Sec. 4001. National Prevention, Health Promotion and Public Health
Council.
Sec. 4002. Prevention and Public Health Fund.
Sec. 4003. Clinical and community preventive services.
Sec. 4004. Education and outreach campaign regarding preventive
benefits.
Subtitle B--Increasing Access to Clinical Preventive Services
Sec. 4101. School-based health centers.
Sec. 4102. Oral healthcare prevention activities.
Sec. 4103. Medicare coverage of annual wellness visit providing a
personalized prevention plan.
Sec. 4104. Removal of barriers to preventive services in Medicare.
Sec. 4105. Evidence-based coverage of preventive services in Medicare.
Sec. 4106. Improving access to preventive services for eligible adults
in Medicaid.
Sec. 4107. Coverage of comprehensive tobacco cessation services for
pregnant women in Medicaid.
Sec. 4108. Incentives for prevention of chronic diseases in medicaid.
Subtitle C--Creating Healthier Communities
Sec. 4201. Community transformation grants.
Sec. 4202. Healthy aging, living well; evaluation of community-based
prevention and wellness programs for Medicare
beneficiaries.
Sec. 4203. Removing barriers and improving access to wellness for
individuals with disabilities.
Sec. 4204. Immunizations.
Sec. 4205. Nutrition labeling of standard menu items at chain
restaurants.
Sec. 4206. Demonstration project concerning individualized wellness
plan.
Sec. 4207. Reasonable break time for nursing mothers.
Subtitle D--Support for Prevention and Public Health Innovation
Sec. 4301. Research on optimizing the delivery of public health
services.
Sec. 4302. Understanding health disparities: data collection and
analysis.
Sec. 4303. CDC and employer-based wellness programs.
Sec. 4304. Epidemiology-Laboratory Capacity Grants.
Sec. 4305. Advancing research and treatment for pain care management.
Sec. 4306. Funding for Childhood Obesity Demonstration Project.
Subtitle E--Miscellaneous Provisions
Sec. 4401. Sense of the Senate concerning CBO scoring.
Sec. 4402. Effectiveness of Federal health and wellness initiatives.
TITLE V--HEALTH CARE WORKFORCE
Subtitle A--Purpose and Definitions
Sec. 5001. Purpose.
Sec. 5002. Definitions.
Subtitle B--Innovations in the Health Care Workforce
Sec. 5101. National health care workforce commission.
[[Page H1923]]
Sec. 5102. State health care workforce development grants.
Sec. 5103. Health care workforce assessment.
Subtitle C--Increasing the Supply of the Health Care Workforce
Sec. 5201. Federally supported student loan funds.
Sec. 5202. Nursing student loan program.
Sec. 5203. Health care workforce loan repayment programs.
Sec. 5204. Public health workforce recruitment and retention programs.
Sec. 5205. Allied health workforce recruitment and retention programs.
Sec. 5206. Grants for State and local programs.
Sec. 5207. Funding for National Health Service Corps.
Sec. 5208. Nurse-managed health clinics.
Sec. 5209. Elimination of cap on commissioned corps.
Sec. 5210. Establishing a Ready Reserve Corps.
Subtitle D--Enhancing Health Care Workforce Education and Training
Sec. 5301. Training in family medicine, general internal medicine,
general pediatrics, and physician assistantship.
Sec. 5302. Training opportunities for direct care workers.
Sec. 5303. Training in general, pediatric, and public health dentistry.
Sec. 5304. Alternative dental health care providers demonstration
project.
Sec. 5305. Geriatric education and training; career awards;
comprehensive geriatric education.
Sec. 5306. Mental and behavioral health education and training grants.
Sec. 5307. Cultural competency, prevention, and public health and
individuals with disabilities training.
Sec. 5308. Advanced nursing education grants.
Sec. 5309. Nurse education, practice, and retention grants.
Sec. 5310. Loan repayment and scholarship program.
Sec. 5311. Nurse faculty loan program.
Sec. 5312. Authorization of appropriations for parts B through D of
title VIII.
Sec. 5313. Grants to promote the community health workforce.
Sec. 5314. Fellowship training in public health.
Sec. 5315. United States Public Health Sciences Track.
Subtitle E--Supporting the Existing Health Care Workforce
Sec. 5401. Centers of excellence.
Sec. 5402. Health care professionals training for diversity.
Sec. 5403. Interdisciplinary, community-based linkages.
Sec. 5404. Workforce diversity grants.
Sec. 5405. Primary care extension program.
Subtitle F--Strengthening Primary Care and Other Workforce Improvements
Sec. 5501. Expanding access to primary care services and general
surgery services.
Sec. 5502. Medicare Federally qualified health center improvements.
Sec. 5503. Distribution of additional residency positions.
Sec. 5504. Counting resident time in nonprovider settings.
Sec. 5505. Rules for counting resident time for didactic and scholarly
activities and other activities.
Sec. 5506. Preservation of resident cap positions from closed
hospitals.
Sec. 5507. Demonstration projects To address health professions
workforce needs; extension of family-to-family health
information centers.
Sec. 5508. Increasing teaching capacity.
Sec. 5509. Graduate nurse education demonstration.
Subtitle G--Improving Access to Health Care Services
Sec. 5601. Spending for Federally Qualified Health Centers (FQHCs).
Sec. 5602. Negotiated rulemaking for development of methodology and
criteria for designating medically underserved
populations and health professions shortage areas.
Sec. 5603. Reauthorization of the Wakefield Emergency Medical Services
for Children Program.
Sec. 5604. Co-locating primary and specialty care in community-based
mental health settings.
Sec. 5605. Key National indicators.
Subtitle H--General Provisions
Sec. 5701. Reports.
TITLE VI--TRANSPARENCY AND PROGRAM INTEGRITY
Subtitle A--Physician Ownership and Other Transparency
Sec. 6001. Limitation on Medicare exception to the prohibition on
certain physician referrals for hospitals.
Sec. 6002. Transparency reports and reporting of physician ownership or
investment interests.
Sec. 6003. Disclosure requirements for in-office ancillary services
exception to the prohibition on physician self-referral
for certain imaging services.
Sec. 6004. Prescription drug sample transparency.
Sec. 6005. Pharmacy benefit managers transparency requirements.
Subtitle B--Nursing Home Transparency and Improvement
PART I--Improving Transparency of Information
Sec. 6101. Required disclosure of ownership and additional disclosable
parties information.
Sec. 6102. Accountability requirements for skilled nursing facilities
and nursing facilities.
Sec. 6103. Nursing home compare Medicare website.
Sec. 6104. Reporting of expenditures.
Sec. 6105. Standardized complaint form.
Sec. 6106. Ensuring staffing accountability.
Sec. 6107. GAO study and report on Five-Star Quality Rating System.
PART II--Targeting Enforcement
Sec. 6111. Civil money penalties.
Sec. 6112. National independent monitor demonstration project.
Sec. 6113. Notification of facility closure.
Sec. 6114. National demonstration projects on culture change and use of
information technology in nursing homes.
PART III--Improving Staff Training
Sec. 6121. Dementia and abuse prevention training.
Subtitle C--Nationwide Program for National and State Background Checks
on Direct Patient Access Employees of Long-term Care Facilities and
Providers
Sec. 6201. Nationwide program for National and State background checks
on direct patient access employees of long-term care
facilities and providers.
Subtitle D--Patient-Centered Outcomes Research
Sec. 6301. Patient-Centered Outcomes Research.
Sec. 6302. Federal coordinating council for comparative effectiveness
research.
Subtitle E--Medicare, Medicaid, and CHIP Program Integrity Provisions
Sec. 6401. Provider screening and other enrollment requirements under
Medicare, Medicaid, and CHIP.
Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions.
Sec. 6403. Elimination of duplication between the Healthcare Integrity
and Protection Data Bank and the National Practitioner
Data Bank.
Sec. 6404. Maximum period for submission of Medicare claims reduced to
not more than 12 months.
Sec. 6405. Physicians who order items or services required to be
Medicare enrolled physicians or eligible professionals.
Sec. 6406. Requirement for physicians to provide documentation on
referrals to programs at high risk of waste and abuse.
Sec. 6407. Face to face encounter with patient required before
physicians may certify eligibility for home health
services or durable medical equipment under Medicare.
Sec. 6408. Enhanced penalties.
Sec. 6409. Medicare self-referral disclosure protocol.
Sec. 6410. Adjustments to the Medicare durable medical equipment,
prosthetics, orthotics, and supplies competitive
acquisition program.
Sec. 6411. Expansion of the Recovery Audit Contractor (RAC) program.
Subtitle F--Additional Medicaid Program Integrity Provisions
Sec. 6501. Termination of provider participation under Medicaid if
terminated under Medicare or other State plan.
Sec. 6502. Medicaid exclusion from participation relating to certain
ownership, control, and management affiliations.
Sec. 6503. Billing agents, clearinghouses, or other alternate payees
required to register under Medicaid.
Sec. 6504. Requirement to report expanded set of data elements under
MMIS to detect fraud and abuse.
Sec. 6505. Prohibition on payments to institutions or entities located
outside of the United States.
Sec. 6506. Overpayments.
Sec. 6507. Mandatory State use of national correct coding initiative.
Sec. 6508. General effective date.
Subtitle G--Additional Program Integrity Provisions
Sec. 6601. Prohibition on false statements and representations.
Sec. 6602. Clarifying definition.
Sec. 6603. Development of model uniform report form.
Sec. 6604. Applicability of State law to combat fraud and abuse.
Sec. 6605. Enabling the Department of Labor to issue administrative
summary cease and desist orders and summary seizures
orders against plans that are in financially hazardous
condition.
Sec. 6606. MEWA plan registration with Department of Labor.
Sec. 6607. Permitting evidentiary privilege and confidential
communications.
Subtitle H--Elder Justice Act
Sec. 6701. Short title of subtitle.
Sec. 6702. Definitions.
Sec. 6703. Elder Justice.
Subtitle I--Sense of the Senate Regarding Medical Malpractice
Sec. 6801. Sense of the Senate regarding medical malpractice.
TITLE VII--IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES
Subtitle A--Biologics Price Competition and Innovation
Sec. 7001. Short title.
Sec. 7002. Approval pathway for biosimilar biological products.
Sec. 7003. Savings.
Subtitle B--More Affordable Medicines for Children and Underserved
Communities
Sec. 7101. Expanded participation in 340B program.
[[Page H1924]]
Sec. 7102. Improvements to 340B program integrity.
Sec. 7103. GAO study to make recommendations on improving the 340B
program.
TITLE VIII--CLASS ACT
Sec. 8001. Short title of title.
Sec. 8002. Establishment of national voluntary insurance program for
purchasing community living assistance services and
support.
TITLE IX--REVENUE PROVISIONS
Subtitle A--Revenue Offset Provisions
Sec. 9001. Excise tax on high cost employer-sponsored health coverage.
Sec. 9002. Inclusion of cost of employer-sponsored health coverage on
W-2.
Sec. 9003. Distributions for medicine qualified only if for prescribed
drug or insulin.
Sec. 9004. Increase in additional tax on distributions from HSAs and
Archer MSAs not used for qualified medical expenses.
Sec. 9005. Limitation on health flexible spending arrangements under
cafeteria plans.
Sec. 9006. Expansion of information reporting requirements.
Sec. 9007. Additional requirements for charitable hospitals.
Sec. 9008. Imposition of annual fee on branded prescription
pharmaceutical manufacturers and importers.
Sec. 9009. Imposition of annual fee on medical device manufacturers and
importers.
Sec. 9010. Imposition of annual fee on health insurance providers.
Sec. 9011. Study and report of effect on veterans health care.
Sec. 9012. Elimination of deduction for expenses allocable to Medicare
Part D subsidy.
Sec. 9013. Modification of itemized deduction for medical expenses.
Sec. 9014. Limitation on excessive remuneration paid by certain health
insurance providers.
Sec. 9015. Additional hospital insurance tax on high-income taxpayers.
Sec. 9016. Modification of section 833 treatment of certain health
organizations.
Sec. 9017. Excise tax on elective cosmetic medical procedures.
Subtitle B--Other Provisions
Sec. 9021. Exclusion of health benefits provided by Indian tribal
governments.
Sec. 9022. Establishment of simple cafeteria plans for small
businesses.
Sec. 9023. Qualifying therapeutic discovery project credit.
TITLE X--STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL
AMERICANS
Subtitle A--Provisions Relating to Title I
Sec. 10101. Amendments to subtitle A.
Sec. 10102. Amendments to subtitle B.
Sec. 10103. Amendments to subtitle C.
Sec. 10104. Amendments to subtitle D.
Sec. 10105. Amendments to subtitle E.
Sec. 10106. Amendments to subtitle F.
Sec. 10107. Amendments to subtitle G.
Sec. 10108. Free choice vouchers.
Sec. 10109. Development of standards for financial and administrative
transactions.
Subtitle B--Provisions Relating to Title II
PART I--Medicaid and CHIP
Sec. 10201. Amendments to the Social Security Act and title II of this
Act.
Sec. 10202. Incentives for States to offer home and community-based
services as a long-term care alternative to nursing
homes.
Sec. 10203. Extension of funding for CHIP through fiscal year 2015 and
other CHIP-related provisions.
PART II--Support for Pregnant and Parenting Teens and Women
Sec. 10211. Definitions.
Sec. 10212. Establishment of pregnancy assistance fund.
Sec. 10213. Permissible uses of Fund.
Sec. 10214. Appropriations.
PART III--Indian Health Care Improvement
Sec. 10221. Indian health care improvement.
Subtitle C--Provisions Relating to Title III
Sec. 10301. Plans for a Value-Based purchasing program for ambulatory
surgical centers.
Sec. 10302. Revision to national strategy for quality improvement in
health care.
Sec. 10303. Development of outcome measures.
Sec. 10304. Selection of efficiency measures.
Sec. 10305. Data collection; public reporting.
Sec. 10306. Improvements under the Center for Medicare and Medicaid
Innovation.
Sec. 10307. Improvements to the Medicare shared savings program.
Sec. 10308. Revisions to national pilot program on payment bundling.
Sec. 10309. Revisions to hospital readmissions reduction program.
Sec. 10310. Repeal of physician payment update.
Sec. 10311. Revisions to extension of ambulance add-ons.
Sec. 10312. Certain payment rules for long-term care hospital services
and moratorium on the establishment of certain hospitals
and facilities.
Sec. 10313. Revisions to the extension for the rural community hospital
demonstration program.
Sec. 10314. Adjustment to low-volume hospital provision.
Sec. 10315. Revisions to home health care provisions.
Sec. 10316. Medicare DSH.
Sec. 10317. Revisions to extension of section 508 hospital provisions.
Sec. 10318. Revisions to transitional extra benefits under Medicare
Advantage.
Sec. 10319. Revisions to market basket adjustments.
Sec. 10320. Expansion of the scope of, and additional improvements to,
the Independent Medicare Advisory Board.
Sec. 10321. Revision to community health teams.
Sec. 10322. Quality reporting for psychiatric hospitals.
Sec. 10323. Medicare coverage for individuals exposed to environmental
health hazards.
Sec. 10324. Protections for frontier States.
Sec. 10325. Revision to skilled nursing facility prospective payment
system.
Sec. 10326. Pilot testing pay-for-performance programs for certain
Medicare providers.
Sec. 10327. Improvements to the physician quality reporting system.
Sec. 10328. Improvement in part D medication therapy management (MTM)
programs.
Sec. 10329. Developing methodology to assess health plan value.
Sec. 10330. Modernizing computer and data systems of the Centers for
Medicare & Medicaid services to support improvements in
care delivery.
Sec. 10331. Public reporting of performance information.
Sec. 10332. Availability of medicare data for performance measurement.
Sec. 10333. Community-based collaborative care networks.
Sec. 10334. Minority health.
Sec. 10335. Technical correction to the hospital value-based purchasing
program.
Sec. 10336. GAO study and report on Medicare beneficiary access to
high-quality dialysis services.
Subtitle D--Provisions Relating to Title IV
Sec. 10401. Amendments to subtitle A.
Sec. 10402. Amendments to subtitle B.
Sec. 10403. Amendments to subtitle C.
Sec. 10404. Amendments to subtitle D.
Sec. 10405. Amendments to subtitle E.
Sec. 10406. Amendment relating to waiving coinsurance for preventive
services.
Sec. 10407. Better diabetes care.
Sec. 10408. Grants for small businesses to provide comprehensive
workplace wellness programs.
Sec. 10409. Cures Acceleration Network.
Sec. 10410. Centers of Excellence for Depression.
Sec. 10411. Programs relating to congenital heart disease.
Sec. 10412. Automated Defibrillation in Adam's Memory Act.
Sec. 10413. Young women's breast health awareness and support of young
women diagnosed with breast cancer.
Subtitle E--Provisions Relating to Title V
Sec. 10501. Amendments to the Public Health Service Act, the Social
Security Act, and title V of this Act.
Sec. 10502. Infrastructure to Expand Access to Care.
Sec. 10503. Community Health Centers and the National Health Service
Corps Fund.
Sec. 10504. Demonstration project to provide access to affordable care.
Subtitle F--Provisions Relating to Title VI
Sec. 10601. Revisions to limitation on medicare exception to the
prohibition on certain physician referrals for hospitals.
Sec. 10602. Clarifications to patient-centered outcomes research.
Sec. 10603. Striking provisions relating to individual provider
application fees.
Sec. 10604. Technical correction to section 6405.
Sec. 10605. Certain other providers permitted to conduct face to face
encounter for home health services.
Sec. 10606. Health care fraud enforcement.
Sec. 10607. State demonstration programs to evaluate alternatives to
current medical tort litigation.
Sec. 10608. Extension of medical malpractice coverage to free clinics.
Sec. 10609. Labeling changes.
Subtitle G--Provisions Relating to Title VIII
Sec. 10801. Provisions relating to title VIII.
Subtitle H--Provisions Relating to Title IX
Sec. 10901. Modifications to excise tax on high cost employer-sponsored
health coverage.
Sec. 10902. Inflation adjustment of limitation on health flexible
spending arrangements under cafeteria plans.
Sec. 10903. Modification of limitation on charges by charitable
hospitals.
Sec. 10904. Modification of annual fee on medical device manufacturers
and importers.
Sec. 10905. Modification of annual fee on health insurance providers.
Sec. 10906. Modifications to additional hospital insurance tax on high-
income taxpayers.
Sec. 10907. Excise tax on indoor tanning services in lieu of elective
cosmetic medical procedures.
Sec. 10908. Exclusion for assistance provided to participants in State
student loan repayment programs for certain health
professionals.
[[Page H1925]]
Sec. 10909. Expansion of adoption credit and adoption assistance
programs.
TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
Subtitle A--Immediate Improvements in Health Care Coverage for All
Americans
SEC. 1001. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.
Part A of title XXVII of the Public Health Service Act (42
U.S.C. 300gg et seq.) is amended--
(1) by striking the part heading and inserting the
following:
``PART A--INDIVIDUAL AND GROUP MARKET REFORMS'';
(2) by redesignating sections 2704 through 2707 as sections
2725 through 2728, respectively;
(3) by redesignating sections 2711 through 2713 as sections
2731 through 2733, respectively;
(4) by redesignating sections 2721 through 2723 as sections
2735 through 2737, respectively; and
(5) by inserting after section 2702, the following:
``Subpart II--Improving Coverage
``SEC. 2711. NO LIFETIME OR ANNUAL LIMITS.
``(a) In General.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage may not establish--
``(1) lifetime limits on the dollar value of benefits for
any participant or beneficiary; or
``(2) unreasonable annual limits (within the meaning of
section 223 of the Internal Revenue Code of 1986) on the
dollar value of benefits for any participant or beneficiary.
``(b) Per Beneficiary Limits.--Subsection (a) shall not be
construed to prevent a group health plan or health insurance
coverage that is not required to provide essential health
benefits under section 1302(b) of the Patient Protection and
Affordable Care Act from placing annual or lifetime per
beneficiary limits on specific covered benefits to the extent
that such limits are otherwise permitted under Federal or
State law.
``SEC. 2712. PROHIBITION ON RESCISSIONS.
``A group health plan and a health insurance issuer
offering group or individual health insurance coverage shall
not rescind such plan or coverage with respect to an enrollee
once the enrollee is covered under such plan or coverage
involved, except that this section shall not apply to a
covered individual who has performed an act or practice that
constitutes fraud or makes an intentional misrepresentation
of material fact as prohibited by the terms of the plan or
coverage. Such plan or coverage may not be cancelled except
with prior notice to the enrollee, and only as permitted
under section 2702(c) or 2742(b).
``SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES.
``(a) In General.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage shall, at a minimum provide coverage for
and shall not impose any cost sharing requirements for--
``(1) evidence-based items or services that have in effect
a rating of `A' or `B' in the current recommendations of the
United States Preventive Services Task Force;
``(2) immunizations that have in effect a recommendation
from the Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention with respect to
the individual involved;
``(3) with respect to infants, children, and adolescents,
evidence-informed preventive care and screenings provided for
in the comprehensive guidelines supported by the Health
Resources and Services Administration;
``(4) with respect to women, such additional preventive
care and screenings not described in paragraph (1) as
provided for in comprehensive guidelines supported by the
Health Resources and Services Administration for purposes of
this paragraph; and
``(5) for the purposes of this Act, and for the purposes of
any other provision of law, the current recommendations of
the United States Preventive Service Task Force regarding
breast cancer screening, mammography, and prevention shall be
considered the most current other than those issued in or
around November 2009.
Nothing in this subsection shall be construed to prohibit a
plan or issuer from providing coverage for services in
addition to those recommended by United States Preventive
Services Task Force or to deny coverage for services that are
not recommended by such Task Force.
``(b) Interval.--
``(1) In general.--The Secretary shall establish a minimum
interval between the date on which a recommendation described
in subsection (a)(1) or (a)(2) or a guideline under
subsection (a)(3) is issued and the plan year with respect to
which the requirement described in subsection (a) is
effective with respect to the service described in such
recommendation or guideline.
``(2) Minimum.--The interval described in paragraph (1)
shall not be less than 1 year.
``(c) Value-Based Insurance Design.--The Secretary may
develop guidelines to permit a group health plan and a health
insurance issuer offering group or individual health
insurance coverage to utilize value-based insurance designs.
``SEC. 2714. EXTENSION OF DEPENDENT COVERAGE.
``(a) In General.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage that provides dependent coverage of
children shall continue to make such coverage available for
an adult child (who is not married) until the child turns 26
years of age. Nothing in this section shall require a health
plan or a health insurance issuer described in the preceding
sentence to make coverage available for a child of a child
receiving dependent coverage.
``(b) Regulations.--The Secretary shall promulgate
regulations to define the dependents to which coverage shall
be made available under subsection (a).
``(c) Rule of Construction.--Nothing in this section shall
be construed to modify the definition of `dependent' as used
in the Internal Revenue Code of 1986 with respect to the tax
treatment of the cost of coverage.
``SEC. 2715. DEVELOPMENT AND UTILIZATION OF UNIFORM
EXPLANATION OF COVERAGE DOCUMENTS AND
STANDARDIZED DEFINITIONS.
``(a) In General.--Not later than 12 months after the date
of enactment of the Patient Protection and Affordable Care
Act, the Secretary shall develop standards for use by a group
health plan and a health insurance issuer offering group or
individual health insurance coverage, in compiling and
providing to enrollees a summary of benefits and coverage
explanation that accurately describes the benefits and
coverage under the applicable plan or coverage. In developing
such standards, the Secretary shall consult with the National
Association of Insurance Commissioners (referred to in this
section as the `NAIC'), a working group composed of
representatives of health insurance-related consumer advocacy
organizations, health insurance issuers, health care
professionals, patient advocates including those representing
individuals with limited English proficiency, and other
qualified individuals.
``(b) Requirements.--The standards for the summary of
benefits and coverage developed under subsection (a) shall
provide for the following:
``(1) Appearance.--The standards shall ensure that the
summary of benefits and coverage is presented in a uniform
format that does not exceed 4 pages in length and does not
include print smaller than 12-point font.
``(2) Language.--The standards shall ensure that the
summary is presented in a culturally and linguistically
appropriate manner and utilizes terminology understandable by
the average plan enrollee.
``(3) Contents.--The standards shall ensure that the
summary of benefits and coverage includes--
``(A) uniform definitions of standard insurance terms and
medical terms (consistent with subsection (g)) so that
consumers may compare health insurance coverage and
understand the terms of coverage (or exception to such
coverage);
``(B) a description of the coverage, including cost sharing
for--
``(i) each of the categories of the essential health
benefits described in subparagraphs (A) through (J) of
section 1302(b)(1) of the Patient Protection and Affordable
Care Act; and
``(ii) other benefits, as identified by the Secretary;
``(C) the exceptions, reductions, and limitations on
coverage;
``(D) the cost-sharing provisions, including deductible,
coinsurance, and co-payment obligations;
``(E) the renewability and continuation of coverage
provisions;
``(F) a coverage facts label that includes examples to
illustrate common benefits scenarios, including pregnancy and
serious or chronic medical conditions and related cost
sharing, such scenarios to be based on recognized clinical
practice guidelines;
``(G) a statement of whether the plan or coverage--
``(i) provides minimum essential coverage (as defined under
section 5000A(f) of the Internal Revenue Code 1986); and
``(ii) ensures that the plan or coverage share of the total
allowed costs of benefits provided under the plan or coverage
is not less than 60 percent of such costs;
``(H) a statement that the outline is a summary of the
policy or certificate and that the coverage document itself
should be consulted to determine the governing contractual
provisions; and
``(I) a contact number for the consumer to call with
additional questions and an Internet web address where a copy
of the actual individual coverage policy or group certificate
of coverage can be reviewed and obtained.
``(c) Periodic Review and Updating.--The Secretary shall
periodically review and update, as appropriate, the standards
developed under this section.
``(d) Requirement To Provide.--
``(1) In general.--Not later than 24 months after the date
of enactment of the Patient Protection and Affordable Care
Act, each entity described in paragraph (3) shall provide,
prior to any enrollment restriction, a summary of benefits
and coverage explanation pursuant to the standards
developed by the Secretary under subsection (a) to--
``(A) an applicant at the time of application;
``(B) an enrollee prior to the time of enrollment or
reenrollment, as applicable; and
``(C) a policyholder or certificate holder at the time of
issuance of the policy or delivery of the certificate.
``(2) Compliance.--An entity described in paragraph (3) is
deemed to be in compliance with this section if the summary
of benefits and coverage described in subsection (a) is
provided in paper or electronic form.
``(3) Entities in general.--An entity described in this
paragraph is--
``(A) a health insurance issuer (including a group health
plan that is not a self-insured plan) offering health
insurance coverage within the United States; or
``(B) in the case of a self-insured group health plan, the
plan sponsor or designated administrator of the plan (as such
terms are defined in section 3(16) of the Employee Retirement
Income Security Act of 1974).
``(4) Notice of modifications.--If a group health plan or
health insurance issuer makes
[[Page H1926]]
any material modification in any of the terms of the plan or
coverage involved (as defined for purposes of section 102 of
the Employee Retirement Income Security Act of 1974) that is
not reflected in the most recently provided summary of
benefits and coverage, the plan or issuer shall provide
notice of such modification to enrollees not later than 60
days prior to the date on which such modification will become
effective.
``(e) Preemption.--The standards developed under subsection
(a) shall preempt any related State standards that require a
summary of benefits and coverage that provides less
information to consumers than that required to be provided
under this section, as determined by the Secretary.
``(f) Failure To Provide.--An entity described in
subsection (d)(3) that willfully fails to provide the
information required under this section shall be subject to a
fine of not more than $1,000 for each such failure. Such
failure with respect to each enrollee shall constitute a
separate offense for purposes of this subsection.
``(g) Development of Standard Definitions.--
``(1) In general.--The Secretary shall, by regulation,
provide for the development of standards for the definitions
of terms used in health insurance coverage, including the
insurance-related terms described in paragraph (2) and the
medical terms described in paragraph (3).
``(2) Insurance-related terms.--The insurance-related terms
described in this paragraph are premium, deductible, co-
insurance, co-payment, out-of-pocket limit, preferred
provider, non-preferred provider, out-of-network co-payments,
UCR (usual, customary and reasonable) fees, excluded
services, grievance and appeals, and such other terms as the
Secretary determines are important to define so that
consumers may compare health insurance coverage and
understand the terms of their coverage.
``(3) Medical terms.--The medical terms described in this
paragraph are hospitalization, hospital outpatient care,
emergency room care, physician services, prescription drug
coverage, durable medical equipment, home health care,
skilled nursing care, rehabilitation services, hospice
services, emergency medical transportation, and such other
terms as the Secretary determines are important to define so
that consumers may compare the medical benefits offered by
health insurance and understand the extent of those medical
benefits (or exceptions to those benefits).
``SEC. 2716. PROHIBITION OF DISCRIMINATION BASED ON SALARY.
``(a) In General.--The plan sponsor of a group health plan
(other than a self-insured plan) may not establish rules
relating to the health insurance coverage eligibility
(including continued eligibility) of any full-time employee
under the terms of the plan that are based on the total
hourly or annual salary of the employee or otherwise
establish eligibility rules that have the effect of
discriminating in favor of higher wage employees.
``(b) Limitation.--Subsection (a) shall not be construed to
prohibit a plan sponsor from establishing contribution
requirements for enrollment in the plan or coverage that
provide for the payment by employees with lower hourly or
annual compensation of a lower dollar or percentage
contribution than the payment required of similarly situated
employees with a higher hourly or annual compensation.
``SEC. 2717. ENSURING THE QUALITY OF CARE.
``(a) Quality Reporting.--
``(1) In general.--Not later than 2 years after the date of
enactment of the Patient Protection and Affordable Care Act,
the Secretary, in consultation with experts in health care
quality and stakeholders, shall develop reporting
requirements for use by a group health plan, and a health
insurance issuer offering group or individual health
insurance coverage, with respect to plan or coverage benefits
and health care provider reimbursement structures that--
``(A) improve health outcomes through the implementation of
activities such as quality reporting, effective case
management, care coordination, chronic disease management,
and medication and care compliance initiatives, including
through the use of the medical homes model as defined for
purposes of section 3602 of the Patient Protection and
Affordable Care Act, for treatment or services under the plan
or coverage;
``(B) implement activities to prevent hospital readmissions
through a comprehensive program for hospital discharge that
includes patient-centered education and counseling,
comprehensive discharge planning, and post discharge
reinforcement by an appropriate health care professional;
``(C) implement activities to improve patient safety and
reduce medical errors through the appropriate use of best
clinical practices, evidence based medicine, and health
information technology under the plan or coverage; and
``(D) implement wellness and health promotion activities.
``(2) Reporting requirements.--
``(A) In general.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage shall annually submit to the Secretary,
and to enrollees under the plan or coverage, a report on
whether the benefits under the plan or coverage satisfy the
elements described in subparagraphs (A) through (D) of
paragraph (1).
``(B) Timing of reports.--A report under subparagraph (A)
shall be made available to an enrollee under the plan or
coverage during each open enrollment period.
``(C) Availability of reports.--The Secretary shall make
reports submitted under subparagraph (A) available to the
public through an Internet website.
``(D) Penalties.--In developing the reporting requirements
under paragraph (1), the Secretary may develop and impose
appropriate penalties for non-compliance with such
requirements.
``(E) Exceptions.--In developing the reporting requirements
under paragraph (1), the Secretary may provide for exceptions
to such requirements for group health plans and health
insurance issuers that substantially meet the goals of this
section.
``(b) Wellness and Prevention Programs.--For purposes of
subsection (a)(1)(D), wellness and health promotion
activities may include personalized wellness and prevention
services, which are coordinated, maintained or delivered by a
health care provider, a wellness and prevention plan manager,
or a health, wellness or prevention services organization
that conducts health risk assessments or offers ongoing face-
to-face, telephonic or web-based intervention efforts for
each of the program's participants, and which may include the
following wellness and prevention efforts:
``(1) Smoking cessation.
``(2) Weight management.
``(3) Stress management.
``(4) Physical fitness.
``(5) Nutrition.
``(6) Heart disease prevention.
``(7) Healthy lifestyle support.
``(8) Diabetes prevention.
``(c) Regulations.--Not later than 2 years after the date
of enactment of the Patient Protection and Affordable Care
Act, the Secretary shall promulgate regulations that provide
criteria for determining whether a reimbursement structure is
described in subsection (a).
``(d) Study and Report.--Not later than 180 days after the
date on which regulations are promulgated under subsection
(c), the Government Accountability Office shall review such
regulations and conduct a study and submit to the Committee
on Health, Education, Labor, and Pensions of the Senate and
the Committee on Energy and Commerce of the House of
Representatives a report regarding the impact the activities
under this section have had on the quality and cost of health
care.
``SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE COVERAGE.
``(a) Clear Accounting for Costs.--A health insurance
issuer offering group or individual health insurance coverage
shall, with respect to each plan year, submit to the
Secretary a report concerning the percentage of total premium
revenue that such coverage expends--
``(1) on reimbursement for clinical services provided to
enrollees under such coverage;
``(2) for activities that improve health care quality; and
``(3) on all other non-claims costs, including an
explanation of the nature of such costs, and excluding State
taxes and licensing or regulatory fees.
The Secretary shall make reports received under this section
available to the public on the Internet website of the
Department of Health and Human Services.
``(b) Ensuring That Consumers Receive Value for Their
Premium Payments.--
``(1) Requirement to provide value for premium payments.--A
health insurance issuer offering group or individual health
insurance coverage shall, with respect to each plan year,
provide an annual rebate to each enrollee under such
coverage, on a pro rata basis, in an amount that is equal to
the amount by which premium revenue expended by the issuer on
activities described in subsection (a)(3) exceeds--
``(A) with respect to a health insurance issuer offering
coverage in the group market, 20 percent, or such lower
percentage as a State may by regulation determine; or
``(B) with respect to a health insurance issuer offering
coverage in the individual market, 25 percent, or such lower
percentage as a State may by regulation determine, except
that such percentage shall be adjusted to the extent the
Secretary determines that the application of such percentage
with a State may destabilize the existing individual market
in such State.
``(2) Consideration in setting percentages.--In determining
the percentages under paragraph (1), a State shall seek to
ensure adequate participation by health insurance issuers,
competition in the health insurance market in the State, and
value for consumers so that premiums are used for clinical
services and quality improvements.
``(3) Termination.--The provisions of this subsection shall
have no force or effect after December 31, 2013.
``(c) Standard Hospital Charges.--Each hospital operating
within the United States shall for each year establish (and
update) and make public (in accordance with guidelines
developed by the Secretary) a list of the hospital's standard
charges for items and services provided by the hospital,
including for diagnosis-related groups established under
section 1886(d)(4) of the Social Security Act.
``(d) Definitions.--The Secretary, in consultation with the
National Association of Insurance Commissions, shall
establish uniform definitions for the activities reported
under subsection (a).
``SEC. 2719. APPEALS PROCESS.
``A group health plan and a health insurance issuer
offering group or individual health insurance coverage shall
implement an effective appeals process for appeals of
coverage determinations and claims, under which the plan or
issuer shall, at a minimum--
``(1) have in effect an internal claims appeal process;
``(2) provide notice to enrollees, in a culturally and
linguistically appropriate manner, of available internal and
external appeals processes, and the availability of any
applicable office of health insurance consumer assistance or
ombudsman established under section 2793 to assist such
enrollees with the appeals processes;
``(3) allow an enrollee to review their file, to present
evidence and testimony as part of the appeals process, and to
receive continued coverage pending the outcome of the appeals
process; and
[[Page H1927]]
``(4) provide an external review process for such plans and
issuers that, at a minimum, includes the consumer protections
set forth in the Uniform External Review Model Act
promulgated by the National Association of Insurance
Commissioners and is binding on such plans.''.
SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION.
Part C of title XXVII of the Public Health Service Act (42
U.S.C. 300gg-91 et seq.) is amended by adding at the end the
following:
``SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION.
``(a) In General.--The Secretary shall award grants to
States to enable such States (or the Exchanges operating in
such States) to establish, expand, or provide support for--
``(1) offices of health insurance consumer assistance; or
``(2) health insurance ombudsman programs.
``(b) Eligibility.--
``(1) In general.--To be eligible to receive a grant, a
State shall designate an independent office of health
insurance consumer assistance, or an ombudsman, that,
directly or in coordination with State health insurance
regulators and consumer assistance organizations, receives
and responds to inquiries and complaints concerning health
insurance coverage with respect to Federal health insurance
requirements and under State law.
``(2) Criteria.--A State that receives a grant under this
section shall comply with criteria established by the
Secretary for carrying out activities under such grant.
``(c) Duties.--The office of health insurance consumer
assistance or health insurance ombudsman shall--
``(1) assist with the filing of complaints and appeals,
including filing appeals with the internal appeal or
grievance process of the group health plan or health
insurance issuer involved and providing information about the
external appeal process;
``(2) collect, track, and quantify problems and inquiries
encountered by consumers;
``(3) educate consumers on their rights and
responsibilities with respect to group health plans and
health insurance coverage;
``(4) assist consumers with enrollment in a group health
plan or health insurance coverage by providing information,
referral, and assistance; and
``(5) resolve problems with obtaining premium tax credits
under section 36B of the Internal Revenue Code of 1986.
``(d) Data Collection.--As a condition of receiving a grant
under subsection (a), an office of health insurance consumer
assistance or ombudsman program shall be required to collect
and report data to the Secretary on the types of problems and
inquiries encountered by consumers. The Secretary shall
utilize such data to identify areas where more enforcement
action is necessary and shall share such information with
State insurance regulators, the Secretary of Labor, and the
Secretary of the Treasury for use in the enforcement
activities of such agencies.
``(e) Funding.--
``(1) Initial funding.--There is hereby appropriated to the
Secretary, out of any funds in the Treasury not otherwise
appropriated, $30,000,000 for the first fiscal year for which
this section applies to carry out this section. Such amount
shall remain available without fiscal year limitation.
``(2) Authorization for subsequent years.--There is
authorized to be appropriated to the Secretary for each
fiscal year following the fiscal year described in paragraph
(1), such sums as may be necessary to carry out this
section.''.
SEC. 1003. ENSURING THAT CONSUMERS GET VALUE FOR THEIR
DOLLARS.
Part C of title XXVII of the Public Health Service Act (42
U.S.C. 300gg-91 et seq.), as amended by section 1002, is
further amended by adding at the end the following:
``SEC. 2794. ENSURING THAT CONSUMERS GET VALUE FOR THEIR
DOLLARS.
``(a) Initial Premium Review Process.--
``(1) In general.--The Secretary, in conjunction with
States, shall establish a process for the annual review,
beginning with the 2010 plan year and subject to subsection
(b)(2)(A), of unreasonable increases in premiums for health
insurance coverage.
``(2) Justification and disclosure.--The process
established under paragraph (1) shall require health
insurance issuers to submit to the Secretary and the relevant
State a justification for an unreasonable premium increase
prior to the implementation of the increase. Such issuers
shall prominently post such information on their Internet
websites. The Secretary shall ensure the public disclosure of
information on such increases and justifications for all
health insurance issuers.
``(b) Continuing Premium Review Process.--
``(1) Informing secretary of premium increase patterns.--As
a condition of receiving a grant under subsection (c)(1), a
State, through its Commissioner of Insurance, shall--
``(A) provide the Secretary with information about trends
in premium increases in health insurance coverage in premium
rating areas in the State; and
``(B) make recommendations, as appropriate, to the State
Exchange about whether particular health insurance issuers
should be excluded from participation in the Exchange based
on a pattern or practice of excessive or unjustified premium
increases.
``(2) Monitoring by secretary of premium increases.--
``(A) In general.--Beginning with plan years beginning in
2014, the Secretary, in conjunction with the States and
consistent with the provisions of subsection (a)(2), shall
monitor premium increases of health insurance coverage
offered through an Exchange and outside of an Exchange.
``(B) Consideration in opening exchange.--In determining
under section 1312(f)(2)(B) of the Patient Protection and
Affordable Care Act whether to offer qualified health plans
in the large group market through an Exchange, the State
shall take into account any excess of premium growth outside
of the Exchange as compared to the rate of such growth inside
the Exchange.
``(c) Grants in Support of Process.--
``(1) Premium review grants during 2010 through 2014.--The
Secretary shall carry out a program to award grants to States
during the 5-year period beginning with fiscal year 2010 to
assist such States in carrying out subsection (a),
including--
``(A) in reviewing and, if appropriate under State law,
approving premium increases for health insurance coverage;
and
``(B) in providing information and recommendations to the
Secretary under subsection (b)(1).
``(2) Funding.--
``(A) In general.--Out of all funds in the Treasury not
otherwise appropriated, there are appropriated to the
Secretary $250,000,000, to be available for expenditure for
grants under paragraph (1) and subparagraph (B).
``(B) Further availability for insurance reform and
consumer protection.--If the amounts appropriated under
subparagraph (A) are not fully obligated under grants under
paragraph (1) by the end of fiscal year 2014, any remaining
funds shall remain available to the Secretary for grants to
States for planning and implementing the insurance reforms
and consumer protections under part A.
``(C) Allocation.--The Secretary shall establish a formula
for determining the amount of any grant to a State under this
subsection. Under such formula--
``(i) the Secretary shall consider the number of plans of
health insurance coverage offered in each State and the
population of the State; and
``(ii) no State qualifying for a grant under paragraph (1)
shall receive less than $1,000,000, or more than $5,000,000
for a grant year.''.
SEC. 1004. EFFECTIVE DATES.
(a) In General.--Except as provided for in subsection (b),
this subtitle (and the amendments made by this subtitle)
shall become effective for plan years beginning on or after
the date that is 6 months after the date of enactment of this
Act, except that the amendments made by sections 1002 and
1003 shall become effective for fiscal years beginning with
fiscal year 2010.
(b) Special Rule.--The amendments made by sections 1002 and
1003 shall take effect on the date of enactment of this Act.
Subtitle B--Immediate Actions to Preserve and Expand Coverage
SEC. 1101. IMMEDIATE ACCESS TO INSURANCE FOR UNINSURED
INDIVIDUALS WITH A PREEXISTING CONDITION.
(a) In General.--Not later than 90 days after the date of
enactment of this Act, the Secretary shall establish a
temporary high risk health insurance pool program to provide
health insurance coverage for eligible individuals during the
period beginning on the date on which such program is
established and ending on January 1, 2014.
(b) Administration.--
(1) In general.--The Secretary may carry out the program
under this section directly or through contracts to eligible
entities.
(2) Eligible entities.--To be eligible for a contract under
paragraph (1), an entity shall--
(A) be a State or nonprofit private entity;
(B) submit to the Secretary an application at such time, in
such manner, and containing such information as the Secretary
may require; and
(C) agree to utilize contract funding to establish and
administer a qualified high risk pool for eligible
individuals.
(3) Maintenance of effort.--To be eligible to enter into a
contract with the Secretary under this subsection, a State
shall agree not to reduce the annual amount the State
expended for the operation of one or more State high risk
pools during the year preceding the year in which such
contract is entered into.
(c) Qualified High Risk Pool.--
(1) In general.--Amounts made available under this section
shall be used to establish a qualified high risk pool that
meets the requirements of paragraph (2).
(2) Requirements.--A qualified high risk pool meets the
requirements of this paragraph if such pool--
(A) provides to all eligible individuals health insurance
coverage that does not impose any preexisting condition
exclusion with respect to such coverage;
(B) provides health insurance coverage--
(i) in which the issuer's share of the total allowed costs
of benefits provided under such coverage is not less than 65
percent of such costs; and
(ii) that has an out of pocket limit not greater than the
applicable amount described in section 223(c)(2) of the
Internal Revenue Code of 1986 for the year involved, except
that the Secretary may modify such limit if necessary to
ensure the pool meets the actuarial value limit under clause
(i);
(C) ensures that with respect to the premium rate charged
for health insurance coverage offered to eligible individuals
through the high risk pool, such rate shall--
(i) except as provided in clause (ii), vary only as
provided for under section 2701 of the Public Health Service
Act (as amended by this Act and notwithstanding the date on
which such amendments take effect);
(ii) vary on the basis of age by a factor of not greater
than 4 to 1; and
(iii) be established at a standard rate for a standard
population; and
(D) meets any other requirements determined appropriate by
the Secretary.
[[Page H1928]]
(d) Eligible Individual.--An individual shall be deemed to
be an eligible individual for purposes of this section if
such individual--
(1) is a citizen or national of the United States or is
lawfully present in the United States (as determined in
accordance with section 1411);
(2) has not been covered under creditable coverage (as
defined in section 2701(c)(1) of the Public Health Service
Act as in effect on the date of enactment of this Act) during
the 6-month period prior to the date on which such individual
is applying for coverage through the high risk pool; and
(3) has a pre-existing condition, as determined in a manner
consistent with guidance issued by the Secretary.
(e) Protection Against Dumping Risk by Insurers.--
(1) In general.--The Secretary shall establish criteria for
determining whether health insurance issuers and employment-
based health plans have discouraged an individual from
remaining enrolled in prior coverage based on that
individual's health status.
(2) Sanctions.--An issuer or employment-based health plan
shall be responsible for reimbursing the program under this
section for the medical expenses incurred by the program for
an individual who, based on criteria established by the
Secretary, the Secretary finds was encouraged by the issuer
to disenroll from health benefits coverage prior to enrolling
in coverage through the program. The criteria shall include
at least the following circumstances:
(A) In the case of prior coverage obtained through an
employer, the provision by the employer, group health plan,
or the issuer of money or other financial consideration for
disenrolling from the coverage.
(B) In the case of prior coverage obtained directly from an
issuer or under an employment-based health plan--
(i) the provision by the issuer or plan of money or other
financial consideration for disenrolling from the coverage;
or
(ii) in the case of an individual whose premium for the
prior coverage exceeded the premium required by the program
(adjusted based on the age factors applied to the prior
coverage)--
(I) the prior coverage is a policy that is no longer being
actively marketed (as defined by the Secretary) by the
issuer; or
(II) the prior coverage is a policy for which duration of
coverage form issue or health status are factors that can be
considered in determining premiums at renewal.
(3) Construction.--Nothing in this subsection shall be
construed as constituting exclusive remedies for violations
of criteria established under paragraph (1) or as preventing
States from applying or enforcing such paragraph or other
provisions under law with respect to health insurance
issuers.
(f) Oversight.--The Secretary shall establish--
(1) an appeals process to enable individuals to appeal a
determination under this section; and
(2) procedures to protect against waste, fraud, and abuse.
(g) Funding; Termination of Authority.--
(1) In general.--There is appropriated to the Secretary,
out of any moneys in the Treasury not otherwise appropriated,
$5,000,000,000 to pay claims against (and the administrative
costs of) the high risk pool under this section that are in
excess of the amount of premiums collected from eligible
individuals enrolled in the high risk pool. Such funds shall
be available without fiscal year limitation.
(2) Insufficient funds.--If the Secretary estimates for any
fiscal year that the aggregate amounts available for the
payment of the expenses of the high risk pool will be less
than the actual amount of such expenses, the Secretary shall
make such adjustments as are necessary to eliminate such
deficit.
(3) Termination of authority.--
(A) In general.--Except as provided in subparagraph (B),
coverage of eligible individuals under a high risk pool in a
State shall terminate on January 1, 2014.
(B) Transition to exchange.--The Secretary shall develop
procedures to provide for the transition of eligible
individuals enrolled in health insurance coverage offered
through a high risk pool established under this section into
qualified health plans offered through an Exchange. Such
procedures shall ensure that there is no lapse in coverage
with respect to the individual and may extend coverage after
the termination of the risk pool involved, if the Secretary
determines necessary to avoid such a lapse.
(4) Limitations.--The Secretary has the authority to stop
taking applications for participation in the program under
this section to comply with the funding limitation provided
for in paragraph (1).
(5) Relation to state laws.--The standards established
under this section shall supersede any State law or
regulation (other than State licensing laws or State laws
relating to plan solvency) with respect to qualified high
risk pools which are established in accordance with this
section.
SEC. 1102. REINSURANCE FOR EARLY RETIREES.
(a) Administration.--
(1) In general.--Not later than 90 days after the date of
enactment of this Act, the Secretary shall establish a
temporary reinsurance program to provide reimbursement to
participating employment-based plans for a portion of the
cost of providing health insurance coverage to early retirees
(and to the eligible spouses, surviving spouses, and
dependents of such retirees) during the period beginning on
the date on which such program is established and ending on
January 1, 2014.
(2) Reference.--In this section:
(A) Health benefits.--The term ``health benefits'' means
medical, surgical, hospital, prescription drug, and such
other benefits as shall be determined by the Secretary,
whether self-funded, or delivered through the purchase of
insurance or otherwise.
(B) Employment-based plan.--The term ``employment-based
plan'' means a group health benefits plan that--
(i) is--
(I) maintained by one or more current or former employers
(including without limitation any State or local government
or political subdivision thereof), employee organization, a
voluntary employees' beneficiary association, or a committee
or board of individuals appointed to administer such plan; or
(II) a multiemployer plan (as defined in section 3(37) of
the Employee Retirement Income Security Act of 1974); and
(ii) provides health benefits to early retirees.
(C) Early retirees.--The term ``early retirees'' means
individuals who are age 55 and older but are not eligible for
coverage under title XVIII of the Social Security Act, and
who are not active employees of an employer maintaining, or
currently contributing to, the employment-based plan or of
any employer that has made substantial contributions to fund
such plan.
(b) Participation.--
(1) Employment-based plan eligibility.--A participating
employment-based plan is an employment-based plan that--
(A) meets the requirements of paragraph (2) with respect to
health benefits provided under the plan; and
(B) submits to the Secretary an application for
participation in the program, at such time, in such manner,
and containing such information as the Secretary shall
require.
(2) Employment-based health benefits.--An employment-based
plan meets the requirements of this paragraph if the plan--
(A) implements programs and procedures to generate cost-
savings with respect to participants with chronic and high-
cost conditions;
(B) provides documentation of the actual cost of medical
claims involved; and
(C) is certified by the Secretary.
(c) Payments.--
(1) Submission of claims.--
(A) In general.--A participating employment-based plan
shall submit claims for reimbursement to the Secretary which
shall contain documentation of the actual costs of the items
and services for which each claim is being submitted.
(B) Basis for claims.--Claims submitted under subparagraph
(A) shall be based on the actual amount expended by the
participating employment-based plan involved within the plan
year for the health benefits provided to an early retiree or
the spouse, surviving spouse, or dependent of such retiree.
In determining the amount of a claim for purposes of this
subsection, the participating employment-based plan shall
take into account any negotiated price concessions (such as
discounts, direct or indirect subsidies, rebates, and direct
or indirect remunerations) obtained by such plan with respect
to such health benefit. For purposes of determining the
amount of any such claim, the costs paid by the early retiree
or the retiree's spouse, surviving spouse, or dependent in
the form of deductibles, co-payments, or co-insurance shall
be included in the amounts paid by the participating
employment-based plan.
(2) Program payments.--If the Secretary determines that a
participating employment-based plan has submitted a valid
claim under paragraph (1), the Secretary shall reimburse such
plan for 80 percent of that portion of the costs attributable
to such claim that exceed $15,000, subject to the limits
contained in paragraph (3).
(3) Limit.--To be eligible for reimbursement under the
program, a claim submitted by a participating employment-
based plan shall not be less than $15,000 nor greater than
$90,000. Such amounts shall be adjusted each fiscal year
based on the percentage increase in the Medical Care
Component of the Consumer Price Index for all urban consumers
(rounded to the nearest multiple of $1,000) for the year
involved.
(4) Use of payments.--Amounts paid to a participating
employment-based plan under this subsection shall be used to
lower costs for the plan. Such payments may be used to reduce
premium costs for an entity described in subsection
(a)(2)(B)(i) or to reduce premium contributions, co-payments,
deductibles, co-insurance, or other out-of-pocket costs for
plan participants. Such payments shall not be used as general
revenues for an entity described in subsection (a)(2)(B)(i).
The Secretary shall develop a mechanism to monitor the
appropriate use of such payments by such entities.
(5) Payments not treated as income.--Payments received
under this subsection shall not be included in determining
the gross income of an entity described in subsection
(a)(2)(B)(i) that is maintaining or currently contributing to
a participating employment-based plan.
(6) Appeals.--The Secretary shall establish--
(A) an appeals process to permit participating employment-
based plans to appeal a determination of the Secretary with
respect to claims submitted under this section; and
(B) procedures to protect against fraud, waste, and abuse
under the program.
(d) Audits.--The Secretary shall conduct annual audits of
claims data submitted by participating employment-based plans
under this section to ensure that such plans are in
compliance with the requirements of this section.
(e) Funding.--There is appropriated to the Secretary, out
of any moneys in the Treasury not otherwise appropriated,
$5,000,000,000 to carry out the program under this section.
Such funds shall be available without fiscal year limitation.
(f) Limitation.--The Secretary has the authority to stop
taking applications for participation in the program based on
the availability of funding under subsection (e).
[[Page H1929]]
SEC. 1103. IMMEDIATE INFORMATION THAT ALLOWS CONSUMERS TO
IDENTIFY AFFORDABLE COVERAGE OPTIONS.
(a) Internet Portal to Affordable Coverage Options.--
(1) Immediate establishment.--Not later than July 1, 2010,
the Secretary, in consultation with the States, shall
establish a mechanism, including an Internet website, through
which a resident of any State may identify affordable health
insurance coverage options in that State.
(2) Connecting to affordable coverage.--An Internet website
established under paragraph (1) shall, to the extent
practicable, provide ways for residents of any State to
receive information on at least the following coverage
options:
(A) Health insurance coverage offered by health insurance
issuers, other than coverage that provides reimbursement only
for the treatment or mitigation of--
(i) a single disease or condition; or
(ii) an unreasonably limited set of diseases or conditions
(as determined by the Secretary);
(B) Medicaid coverage under title XIX of the Social
Security Act.
(C) Coverage under title XXI of the Social Security Act.
(D) A State health benefits high risk pool, to the extent
that such high risk pool is offered in such State; and
(E) Coverage under a high risk pool under section 1101.
(b) Enhancing Comparative Purchasing Options.--
(1) In general.--Not later than 60 days after the date of
enactment of this Act, the Secretary shall develop a
standardized format to be used for the presentation of
information relating to the coverage options described in
subsection (a)(2). Such format shall, at a minimum, require
the inclusion of information on the percentage of total
premium revenue expended on nonclinical costs (as reported
under section 2718(a) of the Public Health Service Act),
eligibility, availability, premium rates, and cost sharing
with respect to such coverage options and be consistent with
the standards adopted for the uniform explanation of coverage
as provided for in section 2715 of the Public Health Service
Act.
(2) Use of format.--The Secretary shall utilize the format
developed under paragraph (1) in compiling information
concerning coverage options on the Internet website
established under subsection (a).
(c) Authority To Contract.--The Secretary may carry out
this section through contracts entered into with qualified
entities.
SEC. 1104. ADMINISTRATIVE SIMPLIFICATION.
(a) Purpose of Administrative Simplification.--Section 261
of the Health Insurance Portability and Accountability Act of
1996 (42 U.S.C. 1320d note) is amended--
(1) by inserting ``uniform'' before ``standards''; and
(2) by inserting ``and to reduce the clerical burden on
patients, health care providers, and health plans'' before
the period at the end.
(b) Operating Rules for Health Information Transactions.--
(1) Definition of operating rules.--Section 1171 of the
Social Security Act (42 U.S.C. 1320d) is amended by adding at
the end the following:
``(9) Operating rules.--The term `operating rules' means
the necessary business rules and guidelines for the
electronic exchange of information that are not defined by a
standard or its implementation specifications as adopted for
purposes of this part.''.
(2) Transaction standards; operating rules and
compliance.--Section 1173 of the Social Security Act (42
U.S.C. 1320d-2) is amended--
(A) in subsection (a)(2), by adding at the end the
following new subparagraph:
``(J) Electronic funds transfers.'';
(B) in subsection (a), by adding at the end the following
new paragraph:
``(4) Requirements for financial and administrative
transactions.--
``(A) In general.--The standards and associated operating
rules adopted by the Secretary shall--
``(i) to the extent feasible and appropriate, enable
determination of an individual's eligibility and financial
responsibility for specific services prior to or at the point
of care;
``(ii) be comprehensive, requiring minimal augmentation by
paper or other communications;
``(iii) provide for timely acknowledgment, response, and
status reporting that supports a transparent claims and
denial management process (including adjudication and
appeals); and
``(iv) describe all data elements (including reason and
remark codes) in unambiguous terms, require that such data
elements be required or conditioned upon set values in other
fields, and prohibit additional conditions (except where
necessary to implement State or Federal law, or to protect
against fraud and abuse).
``(B) Reduction of clerical burden.--In adopting standards
and operating rules for the transactions referred to under
paragraph (1), the Secretary shall seek to reduce the number
and complexity of forms (including paper and electronic
forms) and data entry required by patients and providers.'';
and
(C) by adding at the end the following new subsections:
``(g) Operating Rules.--
``(1) In general.--The Secretary shall adopt a single set
of operating rules for each transaction referred to under
subsection (a)(1) with the goal of creating as much
uniformity in the implementation of the electronic standards
as possible. Such operating rules shall be consensus-based
and reflect the necessary business rules affecting health
plans and health care providers and the manner in which they
operate pursuant to standards issued under Health Insurance
Portability and Accountability Act of 1996.
``(2) Operating rules development.--In adopting operating
rules under this subsection, the Secretary shall consider
recommendations for operating rules developed by a qualified
nonprofit entity that meets the following requirements:
``(A) The entity focuses its mission on administrative
simplification.
``(B) The entity demonstrates a multi-stakeholder and
consensus-based process for development of operating rules,
including representation by or participation from health
plans, health care providers, vendors, relevant Federal
agencies, and other standard development organizations.
``(C) The entity has a public set of guiding principles
that ensure the operating rules and process are open and
transparent, and supports nondiscrimination and conflict of
interest policies that demonstrate a commitment to open,
fair, and nondiscriminatory practices.
``(D) The entity builds on the transaction standards issued
under Health Insurance Portability and Accountability Act of
1996.
``(E) The entity allows for public review and updates of
the operating rules.
``(3) Review and recommendations.--The National Committee
on Vital and Health Statistics shall--
``(A) advise the Secretary as to whether a nonprofit entity
meets the requirements under paragraph (2);
``(B) review the operating rules developed and recommended
by such nonprofit entity;
``(C) determine whether such operating rules represent a
consensus view of the health care stakeholders and are
consistent with and do not conflict with other existing
standards;
``(D) evaluate whether such operating rules are consistent
with electronic standards adopted for health information
technology; and
``(E) submit to the Secretary a recommendation as to
whether the Secretary should adopt such operating rules.
``(4) Implementation.--
``(A) In general.--The Secretary shall adopt operating
rules under this subsection, by regulation in accordance with
subparagraph (C), following consideration of the operating
rules developed by the non-profit entity described in
paragraph (2) and the recommendation submitted by the
National Committee on Vital and Health Statistics under
paragraph (3)(E) and having ensured consultation with
providers.
``(B) Adoption requirements; effective dates.--
``(i) Eligibility for a health plan and health claim
status.--The set of operating rules for eligibility for a
health plan and health claim status transactions shall be
adopted not later than July 1, 2011, in a manner ensuring
that such operating rules are effective not later than
January 1, 2013, and may allow for the use of a machine
readable identification card.
``(ii) Electronic funds transfers and health care payment
and remittance advice.--The set of operating rules for
electronic funds transfers and health care payment and
remittance advice transactions shall--
``(I) allow for automated reconciliation of the electronic
payment with the remittance advice; and
``(II) be adopted not later than July 1, 2012, in a manner
ensuring that such operating rules are effective not later
than January 1, 2014.
``(iii) Health claims or equivalent encounter information,
enrollment and disenrollment in a health plan, health plan
premium payments, referral certification and authorization.--
The set of operating rules for health claims or equivalent
encounter information, enrollment and disenrollment in a
health plan, health plan premium payments, and referral
certification and authorization transactions shall be adopted
not later than July 1, 2014, in a manner ensuring that such
operating rules are effective not later than January 1, 2016.
``(C) Expedited rulemaking.--The Secretary shall promulgate
an interim final rule applying any standard or operating rule
recommended by the National Committee on Vital and Health
Statistics pursuant to paragraph (3). The Secretary shall
accept and consider public comments on any interim final rule
published under this subparagraph for 60 days after the date
of such publication.
``(h) Compliance.--
``(1) Health plan certification.--
``(A) Eligibility for a health plan, health claim status,
electronic funds transfers, health care payment and
remittance advice.--Not later than December 31, 2013, a
health plan shall file a statement with the Secretary, in
such form as the Secretary may require, certifying that the
data and information systems for such plan are in compliance
with any applicable standards (as described under paragraph
(7) of section 1171) and associated operating rules (as
described under paragraph (9) of such section) for electronic
funds transfers, eligibility for a health plan, health claim
status, and health care payment and remittance advice,
respectively.
``(B) Health claims or equivalent encounter information,
enrollment and disenrollment in a health plan, health plan
premium payments, health claims attachments, referral
certification and authorization.--Not later than December 31,
2015, a health plan shall file a statement with the
Secretary, in such form as the Secretary may require,
certifying that the data and information systems for such
plan are in compliance with any applicable standards and
associated operating rules for health claims or equivalent
encounter information, enrollment and disenrollment in a
health plan, health plan premium payments, health claims
attachments, and referral certification and authorization,
respectively. A health plan shall provide the same level of
documentation to certify compliance
[[Page H1930]]
with such transactions as is required to certify compliance
with the transactions specified in subparagraph (A).
``(2) Documentation of compliance.--A health plan shall
provide the Secretary, in such form as the Secretary may
require, with adequate documentation of compliance with the
standards and operating rules described under paragraph (1).
A health plan shall not be considered to have provided
adequate documentation and shall not be certified as being in
compliance with such standards, unless the health plan--
``(A) demonstrates to the Secretary that the plan conducts
the electronic transactions specified in paragraph (1) in a
manner that fully complies with the regulations of the
Secretary; and
``(B) provides documentation showing that the plan has
completed end-to-end testing for such transactions with their
partners, such as hospitals and physicians.
``(3) Service contracts.--A health plan shall be required
to ensure that any entities that provide services pursuant to
a contract with such health plan shall comply with any
applicable certification and compliance requirements (and
provide the Secretary with adequate documentation of such
compliance) under this subsection.
``(4) Certification by outside entity.--The Secretary may
designate independent, outside entities to certify that a
health plan has complied with the requirements under this
subsection, provided that the certification standards
employed by such entities are in accordance with any
standards or operating rules issued by the Secretary.
``(5) Compliance with revised standards and operating
rules.--
``(A) In general.--A health plan (including entities
described under paragraph (3)) shall file a statement with
the Secretary, in such form as the Secretary may require,
certifying that the data and information systems for such
plan are in compliance with any applicable revised standards
and associated operating rules under this subsection for any
interim final rule promulgated by the Secretary under
subsection (i) that--
``(i) amends any standard or operating rule described under
paragraph (1) of this subsection; or
``(ii) establishes a standard (as described under
subsection (a)(1)(B)) or associated operating rules (as
described under subsection (i)(5)) for any other financial
and administrative transactions.
``(B) Date of compliance.--A health plan shall comply with
such requirements not later than the effective date of the
applicable standard or operating rule.
``(6) Audits of health plans.--The Secretary shall conduct
periodic audits to ensure that health plans (including
entities described under paragraph (3)) are in compliance
with any standards and operating rules that are described
under paragraph (1) or subsection (i)(5).
``(i) Review and Amendment of Standards and Operating
Rules.--
``(1) Establishment.--Not later than January 1, 2014, the
Secretary shall establish a review committee (as described
under paragraph (4)).
``(2) Evaluations and reports.--
``(A) Hearings.--Not later than April 1, 2014, and not less
than biennially thereafter, the Secretary, acting through the
review committee, shall conduct hearings to evaluate and
review the adopted standards and operating rules established
under this section.
``(B) Report.--Not later than July 1, 2014, and not less
than biennially thereafter, the review committee shall
provide recommendations for updating and improving such
standards and operating rules. The review committee shall
recommend a single set of operating rules per transaction
standard and maintain the goal of creating as much uniformity
as possible in the implementation of the electronic
standards.
``(3) Interim final rulemaking.--
``(A) In general.--Any recommendations to amend adopted
standards and operating rules that have been approved by the
review committee and reported to the Secretary under
paragraph (2)(B) shall be adopted by the Secretary through
promulgation of an interim final rule not later than 90 days
after receipt of the committee's report.
``(B) Public comment.--
``(i) Public comment period.--The Secretary shall accept
and consider public comments on any interim final rule
published under this paragraph for 60 days after the date of
such publication.
``(ii) Effective date.--The effective date of any amendment
to existing standards or operating rules that is adopted
through an interim final rule published under this paragraph
shall be 25 months following the close of such public comment
period.
``(4) Review committee.--
``(A) Definition.--For the purposes of this subsection, the
term `review committee' means a committee chartered by or
within the Department of Health and Human services that has
been designated by the Secretary to carry out this
subsection, including--
``(i) the National Committee on Vital and Health
Statistics; or
``(ii) any appropriate committee as determined by the
Secretary.
``(B) Coordination of hit standards.--In developing
recommendations under this subsection, the review committee
shall ensure coordination, as appropriate, with the standards
that support the certified electronic health record
technology approved by the Office of the National Coordinator
for Health Information Technology.
``(5) Operating rules for other standards adopted by the
secretary.--The Secretary shall adopt a single set of
operating rules (pursuant to the process described under
subsection (g)) for any transaction for which a standard had
been adopted pursuant to subsection (a)(1)(B).
``(j) Penalties.--
``(1) Penalty fee.--
``(A) In general.--Not later than April 1, 2014, and
annually thereafter, the Secretary shall assess a penalty fee
(as determined under subparagraph (B)) against a health plan
that has failed to meet the requirements under subsection (h)
with respect to certification and documentation of compliance
with--
``(i) the standards and associated operating rules
described under paragraph (1) of such subsection; and
``(ii) a standard (as described under subsection (a)(1)(B))
and associated operating rules (as described under subsection
(i)(5)) for any other financial and administrative
transactions.
``(B) Fee amount.--Subject to subparagraphs (C), (D), and
(E), the Secretary shall assess a penalty fee against a
health plan in the amount of $1 per covered life until
certification is complete. The penalty shall be assessed per
person covered by the plan for which its data systems for
major medical policies are not in compliance and shall be
imposed against the health plan for each day that the plan is
not in compliance with the requirements under subsection (h).
``(C) Additional penalty for misrepresentation.--A health
plan that knowingly provides inaccurate or incomplete
information in a statement of certification or documentation
of compliance under subsection (h) shall be subject to a
penalty fee that is double the amount that would otherwise be
imposed under this subsection.
``(D) Annual fee increase.--The amount of the penalty fee
imposed under this subsection shall be increased on an annual
basis by the annual percentage increase in total national
health care expenditures, as determined by the Secretary.
``(E) Penalty limit.--A penalty fee assessed against a
health plan under this subsection shall not exceed, on an
annual basis--
``(i) an amount equal to $20 per covered life under such
plan; or
``(ii) an amount equal to $40 per covered life under the
plan if such plan has knowingly provided inaccurate or
incomplete information (as described under subparagraph (C)).
``(F) Determination of covered individuals.--The Secretary
shall determine the number of covered lives under a health
plan based upon the most recent statements and filings that
have been submitted by such plan to the Securities and
Exchange Commission.
``(2) Notice and dispute procedure.--The Secretary shall
establish a procedure for assessment of penalty fees under
this subsection that provides a health plan with reasonable
notice and a dispute resolution procedure prior to provision
of a notice of assessment by the Secretary of the Treasury
(as described under paragraph (4)(B)).
``(3) Penalty fee report.--Not later than May 1, 2014, and
annually thereafter, the Secretary shall provide the
Secretary of the Treasury with a report identifying those
health plans that have been assessed a penalty fee under this
subsection.
``(4) Collection of penalty fee.--
``(A) In general.--The Secretary of the Treasury, acting
through the Financial Management Service, shall administer
the collection of penalty fees from health plans that have
been identified by the Secretary in the penalty fee report
provided under paragraph (3).
``(B) Notice.--Not later than August 1, 2014, and annually
thereafter, the Secretary of the Treasury shall provide
notice to each health plan that has been assessed a penalty
fee by the Secretary under this subsection. Such notice shall
include the amount of the penalty fee assessed by the
Secretary and the due date for payment of such fee to the
Secretary of the Treasury (as described in subparagraph (C)).
``(C) Payment due date.--Payment by a health plan for a
penalty fee assessed under this subsection shall be made to
the Secretary of the Treasury not later than November 1,
2014, and annually thereafter.
``(D) Unpaid penalty fees.--Any amount of a penalty fee
assessed against a health plan under this subsection for
which payment has not been made by the due date provided
under subparagraph (C) shall be--
``(i) increased by the interest accrued on such amount, as
determined pursuant to the underpayment rate established
under section 6621 of the Internal Revenue Code of 1986; and
``(ii) treated as a past-due, legally enforceable debt owed
to a Federal agency for purposes of section 6402(d) of the
Internal Revenue Code of 1986.
``(E) Administrative fees.--Any fee charged or allocated
for collection activities conducted by the Financial
Management Service will be passed on to a health plan on a
pro-rata basis and added to any penalty fee collected from
the plan.''.
(c) Promulgation of Rules.--
(1) Unique health plan identifier.--The Secretary shall
promulgate a final rule to establish a unique health plan
identifier (as described in section 1173(b) of the Social
Security Act (42 U.S.C. 1320d-2(b))) based on the input of
the National Committee on Vital and Health Statistics. The
Secretary may do so on an interim final basis and such rule
shall be effective not later than October 1, 2012.
(2) Electronic funds transfer.--The Secretary shall
promulgate a final rule to establish a standard for
electronic funds transfers (as described in section
1173(a)(2)(J) of the Social Security Act, as added by
subsection (b)(2)(A)). The Secretary may do so on an interim
final basis and shall adopt such standard not later than
January 1, 2012, in a manner ensuring that such standard is
effective not later than January 1, 2014.
(3) Health claims attachments.--The Secretary shall
promulgate a final rule to establish
[[Page H1931]]
a transaction standard and a single set of associated
operating rules for health claims attachments (as described
in section 1173(a)(2)(B) of the Social Security Act (42
U.S.C. 1320d-2(a)(2)(B))) that is consistent with the X12
Version 5010 transaction standards. The Secretary may do so
on an interim final basis and shall adopt a transaction
standard and a single set of associated operating rules not
later than January 1, 2014, in a manner ensuring that such
standard is effective not later than January 1, 2016.
(d) Expansion of Electronic Transactions in Medicare.--
Section 1862(a) of the Social Security Act (42 U.S.C.
1395y(a)) is amended--
(1) in paragraph (23), by striking the ``or'' at the end;
(2) in paragraph (24), by striking the period and inserting
``; or''; and
(3) by inserting after paragraph (24) the following new
paragraph:
``(25) not later than January 1, 2014, for which the
payment is other than by electronic funds transfer (EFT) or
an electronic remittance in a form as specified in ASC X12
835 Health Care Payment and Remittance Advice or subsequent
standard.''.
SEC. 1105. EFFECTIVE DATE.
This subtitle shall take effect on the date of enactment of
this Act.
Subtitle C--Quality Health Insurance Coverage for All Americans
PART I--HEALTH INSURANCE MARKET REFORMS
SEC. 1201. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT.
Part A of title XXVII of the Public Health Service Act (42
U.S.C. 300gg et seq.), as amended by section 1001, is further
amended--
(1) by striking the heading for subpart 1 and inserting the
following:
``Subpart I--General Reform'';
(2)(A) in section 2701 (42 U.S.C. 300gg), by striking the
section heading and subsection (a) and inserting the
following:
``SEC. 2704. PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS
OR OTHER DISCRIMINATION BASED ON HEALTH STATUS.
``(a) In General.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage may not impose any preexisting condition
exclusion with respect to such plan or coverage.''; and
(B) by transferring such section (as amended by
subparagraph (A)) so as to appear after the section 2703
added by paragraph (4);
(3)(A) in section 2702 (42 U.S.C. 300gg-1)--
(i) by striking the section heading and all that follows
through subsection (a);
(ii) in subsection (b)--
(I) by striking ``health insurance issuer offering health
insurance coverage in connection with a group health plan''
each place that such appears and inserting ``health insurance
issuer offering group or individual health insurance
coverage''; and
(II) in paragraph (2)(A)--
(aa) by inserting ``or individual'' after ``employer''; and
(bb) by inserting ``or individual health coverage, as the
case may be'' before the semicolon; and
(iii) in subsection (e)--
(I) by striking ``(a)(1)(F)'' and inserting ``(a)(6)'';
(II) by striking ``2701'' and inserting ``2704''; and
(III) by striking ``2721(a)'' and inserting ``2735(a)'';
and
(B) by transferring such section (as amended by
subparagraph (A)) to appear after section 2705(a) as added by
paragraph (4); and
(4) by inserting after the subpart heading (as added by
paragraph (1)) the following:
``SEC. 2701. FAIR HEALTH INSURANCE PREMIUMS.
``(a) Prohibiting Discriminatory Premium Rates.--
``(1) In general.--With respect to the premium rate charged
by a health insurance issuer for health insurance coverage
offered in the individual or small group market--
``(A) such rate shall vary with respect to the particular
plan or coverage involved only by--
``(i) whether such plan or coverage covers an individual or
family;
``(ii) rating area, as established in accordance with
paragraph (2);
``(iii) age, except that such rate shall not vary by more
than 3 to 1 for adults (consistent with section 2707(c)); and
``(iv) tobacco use, except that such rate shall not vary by
more than 1.5 to 1; and
``(B) such rate shall not vary with respect to the
particular plan or coverage involved by any other factor not
described in subparagraph (A).
``(2) Rating area.--
``(A) In general.--Each State shall establish 1 or more
rating areas within that State for purposes of applying the
requirements of this title.
``(B) Secretarial review.--The Secretary shall review the
rating areas established by each State under subparagraph (A)
to ensure the adequacy of such areas for purposes of carrying
out the requirements of this title. If the Secretary
determines a State's rating areas are not adequate, or that a
State does not establish such areas, the Secretary may
establish rating areas for that State.
``(3) Permissible age bands.--The Secretary, in
consultation with the National Association of Insurance
Commissioners, shall define the permissible age bands for
rating purposes under paragraph (1)(A)(iii).
``(4) Application of variations based on age or tobacco
use.--With respect to family coverage under a group health
plan or health insurance coverage, the rating variations
permitted under clauses (iii) and (iv) of paragraph (1)(A)
shall be applied based on the portion of the premium that is
attributable to each family member covered under the plan or
coverage.
``(5) Special rule for large group market.--If a State
permits health insurance issuers that offer coverage in the
large group market in the State to offer such coverage
through the State Exchange (as provided for under section
1312(f)(2)(B) of the Patient Protection and Affordable Care
Act), the provisions of this subsection shall apply to all
coverage offered in such market in the State.
``SEC. 2702. GUARANTEED AVAILABILITY OF COVERAGE.
``(a) Guaranteed Issuance of Coverage in the Individual and
Group Market.--Subject to subsections (b) through (e), each
health insurance issuer that offers health insurance coverage
in the individual or group market in a State must accept
every employer and individual in the State that applies for
such coverage.
``(b) Enrollment.--
``(1) Restriction.--A health insurance issuer described in
subsection (a) may restrict enrollment in coverage described
in such subsection to open or special enrollment periods.
``(2) Establishment.--A health insurance issuer described
in subsection (a) shall, in accordance with the regulations
promulgated under paragraph (3), establish special enrollment
periods for qualifying events (under section 603 of the
Employee Retirement Income Security Act of 1974).
``(3) Regulations.--The Secretary shall promulgate
regulations with respect to enrollment periods under
paragraphs (1) and (2).
``SEC. 2703. GUARANTEED RENEWABILITY OF COVERAGE.
``(a) In General.--Except as provided in this section, if a
health insurance issuer offers health insurance coverage in
the individual or group market, the issuer must renew or
continue in force such coverage at the option of the plan
sponsor or the individual, as applicable.
``SEC. 2705. PROHIBITING DISCRIMINATION AGAINST INDIVIDUAL
PARTICIPANTS AND BENEFICIARIES BASED ON HEALTH
STATUS.
``(a) In General.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage may not establish rules for eligibility
(including continued eligibility) of any individual to enroll
under the terms of the plan or coverage based on any of the
following health status-related factors in relation to the
individual or a dependent of the individual:
``(1) Health status.
``(2) Medical condition (including both physical and mental
illnesses).
``(3) Claims experience.
``(4) Receipt of health care.
``(5) Medical history.
``(6) Genetic information.
``(7) Evidence of insurability (including conditions
arising out of acts of domestic violence).
``(8) Disability.
``(9) Any other health status-related factor determined
appropriate by the Secretary.
``(j) Programs of Health Promotion or Disease Prevention.--
``(1) General provisions.--
``(A) General rule.--For purposes of subsection (b)(2)(B),
a program of health promotion or disease prevention (referred
to in this subsection as a `wellness program') shall be a
program offered by an employer that is designed to promote
health or prevent disease that meets the applicable
requirements of this subsection.
``(B) No conditions based on health status factor.--If none
of the conditions for obtaining a premium discount or rebate
or other reward for participation in a wellness program is
based on an individual satisfying a standard that is related
to a health status factor, such wellness program shall not
violate this section if participation in the program is made
available to all similarly situated individuals and the
requirements of paragraph (2) are complied with.
``(C) Conditions based on health status factor.--If any of
the conditions for obtaining a premium discount or rebate or
other reward for participation in a wellness program is based
on an individual satisfying a standard that is related to a
health status factor, such wellness program shall not violate
this section if the requirements of paragraph (3) are
complied with.
``(2) Wellness programs not subject to requirements.--If
none of the conditions for obtaining a premium discount or
rebate or other reward under a wellness program as described
in paragraph (1)(B) are based on an individual satisfying a
standard that is related to a health status factor (or if
such a wellness program does not provide such a reward), the
wellness program shall not violate this section if
participation in the program is made available to all
similarly situated individuals. The following programs shall
not have to comply with the requirements of paragraph (3) if
participation in the program is made available to all
similarly situated individuals:
``(A) A program that reimburses all or part of the cost for
memberships in a fitness center.
``(B) A diagnostic testing program that provides a reward
for participation and does not base any part of the reward on
outcomes.
``(C) A program that encourages preventive care related to
a health condition through the waiver of the copayment or
deductible requirement under group health plan for the costs
of certain items or services related to a health condition
(such as prenatal care or well-baby visits).
``(D) A program that reimburses individuals for the costs
of smoking cessation programs without regard to whether the
individual quits smoking.
``(E) A program that provides a reward to individuals for
attending a periodic health education seminar.
``(3) Wellness programs subject to requirements.--If any of
the conditions for obtaining a premium discount, rebate, or
reward
[[Page H1932]]
under a wellness program as described in paragraph (1)(C) is
based on an individual satisfying a standard that is related
to a health status factor, the wellness program shall not
violate this section if the following requirements are
complied with:
``(A) The reward for the wellness program, together with
the reward for other wellness programs with respect to the
plan that requires satisfaction of a standard related to a
health status factor, shall not exceed 30 percent of the cost
of employee-only coverage under the plan. If, in addition to
employees or individuals, any class of dependents (such as
spouses or spouses and dependent children) may participate
fully in the wellness program, such reward shall not exceed
30 percent of the cost of the coverage in which an employee
or individual and any dependents are enrolled. For purposes
of this paragraph, the cost of coverage shall be determined
based on the total amount of employer and employee
contributions for the benefit package under which the
employee is (or the employee and any dependents are)
receiving coverage. A reward may be in the form of a discount
or rebate of a premium or contribution, a waiver of all or
part of a cost-sharing mechanism (such as deductibles,
copayments, or coinsurance), the absence of a surcharge, or
the value of a benefit that would otherwise not be provided
under the plan. The Secretaries of Labor, Health and Human
Services, and the Treasury may increase the reward available
under this subparagraph to up to 50 percent of the cost of
coverage if the Secretaries determine that such an increase
is appropriate.
``(B) The wellness program shall be reasonably designed to
promote health or prevent disease. A program complies with
the preceding sentence if the program has a reasonable chance
of improving the health of, or preventing disease in,
participating individuals and it is not overly burdensome, is
not a subterfuge for discriminating based on a health status
factor, and is not highly suspect in the method chosen to
promote health or prevent disease.
``(C) The plan shall give individuals eligible for the
program the opportunity to qualify for the reward under the
program at least once each year.
``(D) The full reward under the wellness program shall be
made available to all similarly situated individuals. For
such purpose, among other things:
``(i) The reward is not available to all similarly situated
individuals for a period unless the wellness program allows--
``(I) for a reasonable alternative standard (or waiver of
the otherwise applicable standard) for obtaining the reward
for any individual for whom, for that period, it is
unreasonably difficult due to a medical condition to satisfy
the otherwise applicable standard; and
``(II) for a reasonable alternative standard (or waiver of
the otherwise applicable standard) for obtaining the reward
for any individual for whom, for that period, it is medically
inadvisable to attempt to satisfy the otherwise applicable
standard.
``(ii) If reasonable under the circumstances, the plan or
issuer may seek verification, such as a statement from an
individual's physician, that a health status factor makes it
unreasonably difficult or medically inadvisable for the
individual to satisfy or attempt to satisfy the otherwise
applicable standard.
``(E) The plan or issuer involved shall disclose in all
plan materials describing the terms of the wellness program
the availability of a reasonable alternative standard (or the
possibility of waiver of the otherwise applicable standard)
required under subparagraph (D). If plan materials disclose
that such a program is available, without describing its
terms, the disclosure under this subparagraph shall not be
required.
``(k) Existing Programs.--Nothing in this section shall
prohibit a program of health promotion or disease prevention
that was established prior to the date of enactment of this
section and applied with all applicable regulations, and that
is operating on such date, from continuing to be carried out
for as long as such regulations remain in effect.
``(l) Wellness Program Demonstration Project.--
``(1) In general.--Not later than July 1, 2014, the
Secretary, in consultation with the Secretary of the Treasury
and the Secretary of Labor, shall establish a 10-State
demonstration project under which participating States shall
apply the provisions of subsection (j) to programs of health
promotion offered by a health insurance issuer that offers
health insurance coverage in the individual market in such
State.
``(2) Expansion of demonstration project.--If the
Secretary, in consultation with the Secretary of the Treasury
and the Secretary of Labor, determines that the demonstration
project described in paragraph (1) is effective, such
Secretaries may, beginning on July 1, 2017 expand such
demonstration project to include additional participating
States.
``(3) Requirements.--
``(A) Maintenance of coverage.--The Secretary, in
consultation with the Secretary of the Treasury and the
Secretary of Labor, shall not approve the participation of a
State in the demonstration project under this section unless
the Secretaries determine that the State's project is
designed in a manner that--
``(i) will not result in any decrease in coverage; and
``(ii) will not increase the cost to the Federal Government
in providing credits under section 36B of the Internal
Revenue Code of 1986 or cost-sharing assistance under section
1402 of the Patient Protection and Affordable Care Act.
``(B) Other requirements.--States that participate in the
demonstration project under this subsection--
``(i) may permit premium discounts or rebates or the
modification of otherwise applicable copayments or
deductibles for adherence to, or participation in, a
reasonably designed program of health promotion and disease
prevention;
``(ii) shall ensure that requirements of consumer
protection are met in programs of health promotion in the
individual market;
``(iii) shall require verification from health insurance
issuers that offer health insurance coverage in the
individual market of such State that premium discounts--
``(I) do not create undue burdens for individuals insured
in the individual market;
``(II) do not lead to cost shifting; and
``(III) are not a subterfuge for discrimination;
``(iv) shall ensure that consumer data is protected in
accordance with the requirements of section 264(c) of the
Health Insurance Portability and Accountability Act of 1996
(42 U.S.C. 1320d-2 note); and
``(v) shall ensure and demonstrate to the satisfaction of
the Secretary that the discounts or other rewards provided
under the project reflect the expected level of participation
in the wellness program involved and the anticipated effect
the program will have on utilization or medical claim costs.
``(m) Report.--
``(1) In general.--Not later than 3 years after the date of
enactment of the Patient Protection and Affordable Care Act,
the Secretary, in consultation with the Secretary of the
Treasury and the Secretary of Labor, shall submit a report to
the appropriate committees of Congress concerning--
``(A) the effectiveness of wellness programs (as defined in
subsection (j)) in promoting health and preventing disease;
``(B) the impact of such wellness programs on the access to
care and affordability of coverage for participants and non-
participants of such programs;
``(C) the impact of premium-based and cost-sharing
incentives on participant behavior and the role of such
programs in changing behavior; and
``(D) the effectiveness of different types of rewards.
``(2) Data collection.--In preparing the report described
in paragraph (1), the Secretaries shall gather relevant
information from employers who provide employees with access
to wellness programs, including State and Federal agencies.
``(n) Regulations.--Nothing in this section shall be
construed as prohibiting the Secretaries of Labor, Health and
Human Services, or the Treasury from promulgating regulations
in connection with this section.
``SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE.
``(a) Providers.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage shall not discriminate with respect to
participation under the plan or coverage against any health
care provider who is acting within the scope of that
provider's license or certification under applicable State
law. This section shall not require that a group health plan
or health insurance issuer contract with any health care
provider willing to abide by the terms and conditions for
participation established by the plan or issuer. Nothing in
this section shall be construed as preventing a group health
plan, a health insurance issuer, or the Secretary from
establishing varying reimbursement rates based on quality or
performance measures.
``(b) Individuals.--The provisions of section 1558 of the
Patient Protection and Affordable Care Act (relating to non-
discrimination) shall apply with respect to a group health
plan or health insurance issuer offering group or individual
health insurance coverage.
``SEC. 2707. COMPREHENSIVE HEALTH INSURANCE COVERAGE.
``(a) Coverage for Essential Health Benefits Package.--A
health insurance issuer that offers health insurance coverage
in the individual or small group market shall ensure that
such coverage includes the essential health benefits package
required under section 1302(a) of the Patient Protection and
Affordable Care Act.
``(b) Cost-sharing Under Group Health Plans.--A group
health plan shall ensure that any annual cost-sharing imposed
under the plan does not exceed the limitations provided for
under paragraphs (1) and (2) of section 1302(c).
``(c) Child-only Plans.--If a health insurance issuer
offers health insurance coverage in any level of coverage
specified under section 1302(d) of the Patient Protection and
Affordable Care Act, the issuer shall also offer such
coverage in that level as a plan in which the only enrollees
are individuals who, as of the beginning of a plan year, have
not attained the age of 21.
``(d) Dental Only.--This section shall not apply to a plan
described in section 1302(d)(2)(B)(ii)(I).
``SEC. 2708. PROHIBITION ON EXCESSIVE WAITING PERIODS.
``A group health plan and a health insurance issuer
offering group or individual health insurance coverage shall
not apply any waiting period (as defined in section
2704(b)(4)) that exceeds 90 days.''.
PART II--OTHER PROVISIONS
SEC. 1251. PRESERVATION OF RIGHT TO MAINTAIN EXISTING
COVERAGE.
(a) No Changes to Existing Coverage.--
(1) In general.--Nothing in this Act (or an amendment made
by this Act) shall be construed to require that an individual
terminate coverage under a group health plan or health
insurance coverage in which such individual was enrolled on
the date of enactment of this Act.
(2) Continuation of coverage.--With respect to a group
health plan or health insurance coverage in which an
individual was enrolled on the date of enactment of this Act,
this subtitle and subtitle A (and the amendments made by such
subtitles) shall not apply to such plan or
[[Page H1933]]
coverage, regardless of whether the individual renews such
coverage after such date of enactment.
(b) Allowance for Family Members To Join Current
Coverage.--With respect to a group health plan or health
insurance coverage in which an individual was enrolled on the
date of enactment of this Act and which is renewed after such
date, family members of such individual shall be permitted to
enroll in such plan or coverage if such enrollment is
permitted under the terms of the plan in effect as of such
date of enactment.
(c) Allowance for New Employees To Join Current Plan.--A
group health plan that provides coverage on the date of
enactment of this Act may provide for the enrolling of new
employees (and their families) in such plan, and this
subtitle and subtitle A (and the amendments made by such
subtitles) shall not apply with respect to such plan and such
new employees (and their families).
(d) Effect on Collective Bargaining Agreements.--In the
case of health insurance coverage maintained pursuant to one
or more collective bargaining agreements between employee
representatives and one or more employers that was ratified
before the date of enactment of this Act, the provisions of
this subtitle and subtitle A (and the amendments made by such
subtitles) shall not apply until the date on which the last
of the collective bargaining agreements relating to the
coverage terminates. Any coverage amendment made pursuant to
a collective bargaining agreement relating to the coverage
which amends the coverage solely to conform to any
requirement added by this subtitle or subtitle A (or
amendments) shall not be treated as a termination of such
collective bargaining agreement.
(e) Definition.--In this title, the term ``grandfathered
health plan'' means any group health plan or health insurance
coverage to which this section applies.
SEC. 1252. RATING REFORMS MUST APPLY UNIFORMLY TO ALL HEALTH
INSURANCE ISSUERS AND GROUP HEALTH PLANS.
Any standard or requirement adopted by a State pursuant to
this title, or any amendment made by this title, shall be
applied uniformly to all health plans in each insurance
market to which the standard and requirements apply. The
preceding sentence shall also apply to a State standard or
requirement relating to the standard or requirement required
by this title (or any such amendment) that is not the same as
the standard or requirement but that is not preempted under
section 1321(d).
SEC. 1253. EFFECTIVE DATES.
This subtitle (and the amendments made by this subtitle)
shall become effective for plan years beginning on or after
January 1, 2014.
Subtitle D--Available Coverage Choices for All Americans
PART I--ESTABLISHMENT OF QUALIFIED HEALTH PLANS
SEC. 1301. QUALIFIED HEALTH PLAN DEFINED.
(a) Qualified Health Plan.--In this title:
(1) In general.--The term ``qualified health plan'' means a
health plan that--
(A) has in effect a certification (which may include a seal
or other indication of approval) that such plan meets the
criteria for certification described in section 1311(c)
issued or recognized by each Exchange through which such plan
is offered;
(B) provides the essential health benefits package
described in section 1302(a); and
(C) is offered by a health insurance issuer that--
(i) is licensed and in good standing to offer health
insurance coverage in each State in which such issuer offers
health insurance coverage under this title;
(ii) agrees to offer at least one qualified health plan in
the silver level and at least one plan in the gold level in
each such Exchange;
(iii) agrees to charge the same premium rate for each
qualified health plan of the issuer without regard to whether
the plan is offered through an Exchange or whether the plan
is offered directly from the issuer or through an agent; and
(iv) complies with the regulations developed by the
Secretary under section 1311(d) and such other requirements
as an applicable Exchange may establish.
(2) Inclusion of co-op plans and community health insurance
option.--Any reference in this title to a qualified health
plan shall be deemed to include a qualified health plan
offered through the CO-OP program under section 1322 or a
community health insurance option under section 1323, unless
specifically provided for otherwise.
(b) Terms Relating to Health Plans.--In this title:
(1) Health plan.--
(A) In general.--The term ``health plan'' means health
insurance coverage and a group health plan.
(B) Exception for self-insured plans and mewas.--Except to
the extent specifically provided by this title, the term
``health plan'' shall not include a group health plan or
multiple employer welfare arrangement to the extent the plan
or arrangement is not subject to State insurance regulation
under section 514 of the Employee Retirement Income Security
Act of 1974.
(2) Health insurance coverage and issuer.--The terms
``health insurance coverage'' and ``health insurance issuer''
have the meanings given such terms by section 2791(b) of the
Public Health Service Act.
(3) Group health plan.--The term ``group health plan'' has
the meaning given such term by section 2791(a) of the Public
Health Service Act.
SEC. 1302. ESSENTIAL HEALTH BENEFITS REQUIREMENTS.
(a) Essential Health Benefits Package.--In this title, the
term ``essential health benefits package'' means, with
respect to any health plan, coverage that--
(1) provides for the essential health benefits defined by
the Secretary under subsection (b);
(2) limits cost-sharing for such coverage in accordance
with subsection (c); and
(3) subject to subsection (e), provides either the bronze,
silver, gold, or platinum level of coverage described in
subsection (d).
(b) Essential Health Benefits.--
(1) In general.--Subject to paragraph (2), the Secretary
shall define the essential health benefits, except that such
benefits shall include at least the following general
categories and the items and services covered within the
categories:
(A) Ambulatory patient services.
(B) Emergency services.
(C) Hospitalization.
(D) Maternity and newborn care.
(E) Mental health and substance use disorder services,
including behavioral health treatment.
(F) Prescription drugs.
(G) Rehabilitative and habilitative services and devices.
(H) Laboratory services.
(I) Preventive and wellness services and chronic disease
management.
(J) Pediatric services, including oral and vision care.
(2) Limitation.--
(A) In general.--The Secretary shall ensure that the scope
of the essential health benefits under paragraph (1) is equal
to the scope of benefits provided under a typical employer
plan, as determined by the Secretary. To inform this
determination, the Secretary of Labor shall conduct a survey
of employer-sponsored coverage to determine the benefits
typically covered by employers, including multiemployer
plans, and provide a report on such survey to the Secretary.
(B) Certification.--In defining the essential health
benefits described in paragraph (1), and in revising the
benefits under paragraph (4)(H), the Secretary shall submit a
report to the appropriate committees of Congress containing a
certification from the Chief Actuary of the Centers for
Medicare & Medicaid Services that such essential health
benefits meet the limitation described in paragraph (2).
(3) Notice and hearing.--In defining the essential health
benefits described in paragraph (1), and in revising the
benefits under paragraph (4)(H), the Secretary shall provide
notice and an opportunity for public comment.
(4) Required elements for consideration.--In defining the
essential health benefits under paragraph (1), the Secretary
shall--
(A) ensure that such essential health benefits reflect an
appropriate balance among the categories described in such
subsection, so that benefits are not unduly weighted toward
any category;
(B) not make coverage decisions, determine reimbursement
rates, establish incentive programs, or design benefits in
ways that discriminate against individuals because of their
age, disability, or expected length of life;
(C) take into account the health care needs of diverse
segments of the population, including women, children,
persons with disabilities, and other groups;
(D) ensure that health benefits established as essential
not be subject to denial to individuals against their wishes
on the basis of the individuals' age or expected length of
life or of the individuals' present or predicted disability,
degree of medical dependency, or quality of life;
(E) provide that a qualified health plan shall not be
treated as providing coverage for the essential health
benefits described in paragraph (1) unless the plan provides
that--
(i) coverage for emergency department services will be
provided without imposing any requirement under the plan for
prior authorization of services or any limitation on coverage
where the provider of services does not have a contractual
relationship with the plan for the providing of services that
is more restrictive than the requirements or limitations that
apply to emergency department services received from
providers who do have such a contractual relationship with
the plan; and
(ii) if such services are provided out-of-network, the
cost-sharing requirement (expressed as a copayment amount or
coinsurance rate) is the same requirement that would apply if
such services were provided in-network;
(F) provide that if a plan described in section
1311(b)(2)(B)(ii) (relating to stand-alone dental benefits
plans) is offered through an Exchange, another health plan
offered through such Exchange shall not fail to be treated as
a qualified health plan solely because the plan does not
offer coverage of benefits offered through the stand-alone
plan that are otherwise required under paragraph (1)(J); and
(G) periodically review the essential health benefits under
paragraph (1), and provide a report to Congress and the
public that contains--
(i) an assessment of whether enrollees are facing any
difficulty accessing needed services for reasons of coverage
or cost;
(ii) an assessment of whether the essential health benefits
needs to be modified or updated to account for changes in
medical evidence or scientific advancement;
(iii) information on how the essential health benefits will
be modified to address any such gaps in access or changes in
the evidence base;
(iv) an assessment of the potential of additional or
expanded benefits to increase costs and the interactions
between the addition or expansion of benefits and reductions
in existing benefits to meet actuarial limitations described
in paragraph (2); and
(H) periodically update the essential health benefits under
paragraph (1) to address any gaps in access to coverage or
changes in the evidence base the Secretary identifies in the
review conducted under subparagraph (G).
[[Page H1934]]
(5) Rule of construction.--Nothing in this title shall be
construed to prohibit a health plan from providing benefits
in excess of the essential health benefits described in this
subsection.
(c) Requirements Relating to Cost-Sharing.--
(1) Annual limitation on cost-sharing.--
(A) 2014.--The cost-sharing incurred under a health plan
with respect to self-only coverage or coverage other than
self-only coverage for a plan year beginning in 2014 shall
not exceed the dollar amounts in effect under section
223(c)(2)(A)(ii) of the Internal Revenue Code of 1986 for
self-only and family coverage, respectively, for taxable
years beginning in 2014.
(B) 2015 and later.--In the case of any plan year beginning
in a calendar year after 2014, the limitation under this
paragraph shall--
(i) in the case of self-only coverage, be equal to the
dollar amount under subparagraph (A) for self-only coverage
for plan years beginning in 2014, increased by an amount
equal to the product of that amount and the premium
adjustment percentage under paragraph (4) for the calendar
year; and
(ii) in the case of other coverage, twice the amount in
effect under clause (i).
If the amount of any increase under clause (i) is not a
multiple of $50, such increase shall be rounded to the next
lowest multiple of $50.
(2) Annual limitation on deductibles for employer-sponsored
plans.--
(A) In general.--In the case of a health plan offered in
the small group market, the deductible under the plan shall
not exceed--
(i) $2,000 in the case of a plan covering a single
individual; and
(ii) $4,000 in the case of any other plan.
The amounts under clauses (i) and (ii) may be increased by
the maximum amount of reimbursement which is reasonably
available to a participant under a flexible spending
arrangement described in section 106(c)(2) of the Internal
Revenue Code of 1986 (determined without regard to any salary
reduction arrangement).
(B) Indexing of limits.--In the case of any plan year
beginning in a calendar year after 2014--
(i) the dollar amount under subparagraph (A)(i) shall be
increased by an amount equal to the product of that amount
and the premium adjustment percentage under paragraph (4) for
the calendar year; and
(ii) the dollar amount under subparagraph (A)(ii) shall be
increased to an amount equal to twice the amount in effect
under subparagraph (A)(i) for plan years beginning in the
calendar year, determined after application of clause (i).
If the amount of any increase under clause (i) is not a
multiple of $50, such increase shall be rounded to the next
lowest multiple of $50.
(C) Actuarial value.--The limitation under this paragraph
shall be applied in such a manner so as to not affect the
actuarial value of any health plan, including a plan in the
bronze level.
(D) Coordination with preventive limits.--Nothing in this
paragraph shall be construed to allow a plan to have a
deductible under the plan apply to benefits described in
section 2713 of the Public Health Service Act.
(3) Cost-sharing.--In this title--
(A) In general.--The term ``cost-sharing'' includes--
(i) deductibles, coinsurance, copayments, or similar
charges; and
(ii) any other expenditure required of an insured
individual which is a qualified medical expense (within the
meaning of section 223(d)(2) of the Internal Revenue Code of
1986) with respect to essential health benefits covered under
the plan.
(B) Exceptions.--Such term does not include premiums,
balance billing amounts for non-network providers, or
spending for non-covered services.
(4) Premium adjustment percentage.--For purposes of
paragraphs (1)(B)(i) and (2)(B)(i), the premium adjustment
percentage for any calendar year is the percentage (if any)
by which the average per capita premium for health insurance
coverage in the United States for the preceding calendar year
(as estimated by the Secretary no later than October 1 of
such preceding calendar year) exceeds such average per capita
premium for 2013 (as determined by the Secretary).
(d) Levels of Coverage.--
(1) Levels of coverage defined.--The levels of coverage
described in this subsection are as follows:
(A) Bronze level.--A plan in the bronze level shall provide
a level of coverage that is designed to provide benefits that
are actuarially equivalent to 60 percent of the full
actuarial value of the benefits provided under the plan.
(B) Silver level.--A plan in the silver level shall provide
a level of coverage that is designed to provide benefits that
are actuarially equivalent to 70 percent of the full
actuarial value of the benefits provided under the plan.
(C) Gold level.--A plan in the gold level shall provide a
level of coverage that is designed to provide benefits that
are actuarially equivalent to 80 percent of the full
actuarial value of the benefits provided under the plan.
(D) Platinum level.--A plan in the platinum level shall
provide a level of coverage that is designed to provide
benefits that are actuarially equivalent to 90 percent of the
full actuarial value of the benefits provided under the plan.
(2) Actuarial value.--
(A) In general.--Under regulations issued by the Secretary,
the level of coverage of a plan shall be determined on the
basis that the essential health benefits described in
subsection (b) shall be provided to a standard population
(and without regard to the population the plan may actually
provide benefits to).
(B) Employer contributions.--The Secretary may issue
regulations under which employer contributions to a health
savings account (within the meaning of section 223 of the
Internal Revenue Code of 1986) may be taken into account in
determining the level of coverage for a plan of the employer.
(C) Application.--In determining under this title, the
Public Health Service Act, or the Internal Revenue Code of
1986 the percentage of the total allowed costs of benefits
provided under a group health plan or health insurance
coverage that are provided by such plan or coverage, the
rules contained in the regulations under this paragraph shall
apply.
(3) Allowable variance.--The Secretary shall develop
guidelines to provide for a de minimis variation in the
actuarial valuations used in determining the level of
coverage of a plan to account for differences in actuarial
estimates.
(4) Plan reference.--In this title, any reference to a
bronze, silver, gold, or platinum plan shall be treated as a
reference to a qualified health plan providing a bronze,
silver, gold, or platinum level of coverage, as the case may
be.
(e) Catastrophic Plan.--
(1) In general.--A health plan not providing a bronze,
silver, gold, or platinum level of coverage shall be treated
as meeting the requirements of subsection (d) with respect to
any plan year if--
(A) the only individuals who are eligible to enroll in the
plan are individuals described in paragraph (2); and
(B) the plan provides--
(i) except as provided in clause (ii), the essential health
benefits determined under subsection (b), except that the
plan provides no benefits for any plan year until the
individual has incurred cost-sharing expenses in an amount
equal to the annual limitation in effect under subsection
(c)(1) for the plan year (except as provided for in section
2713); and
(ii) coverage for at least three primary care visits.
(2) Individuals eligible for enrollment.--An individual is
described in this paragraph for any plan year if the
individual--
(A) has not attained the age of 30 before the beginning of
the plan year; or
(B) has a certification in effect for any plan year under
this title that the individual is exempt from the requirement
under section 5000A of the Internal Revenue Code of 1986 by
reason of--
(i) section 5000A(e)(1) of such Code (relating to
individuals without affordable coverage); or
(ii) section 5000A(e)(5) of such Code (relating to
individuals with hardships).
(3) Restriction to individual market.--If a health
insurance issuer offers a health plan described in this
subsection, the issuer may only offer the plan in the
individual market.
(f) Child-only Plans.--If a qualified health plan is
offered through the Exchange in any level of coverage
specified under subsection (d), the issuer shall also offer
that plan through the Exchange in that level as a plan in
which the only enrollees are individuals who, as of the
beginning of a plan year, have not attained the age of 21,
and such plan shall be treated as a qualified health plan.
SEC. 1303. SPECIAL RULES.
(a) Special Rules Relating to Coverage of Abortion
Services.--
(1) Voluntary choice of coverage of abortion services.--
(A) In general.--Notwithstanding any other provision of
this title (or any amendment made by this title), and subject
to subparagraphs (C) and (D)--
(i) nothing in this title (or any amendment made by this
title), shall be construed to require a qualified health plan
to provide coverage of services described in subparagraph
(B)(i) or (B)(ii) as part of its essential health benefits
for any plan year; and
(ii) the issuer of a qualified health plan shall determine
whether or not the plan provides coverage of services
described in subparagraph (B)(i) or (B)(ii) as part of such
benefits for the plan year.
(B) Abortion services.--
(i) Abortions for which public funding is prohibited.--The
services described in this clause are abortions for which the
expenditure of Federal funds appropriated for the Department
of Health and Human Services is not permitted, based on the
law as in effect as of the date that is 6 months before the
beginning of the plan year involved.
(ii) Abortions for which public funding is allowed.--The
services described in this clause are abortions for which the
expenditure of Federal funds appropriated for the Department
of Health and Human Services is permitted, based on the law
as in effect as of the date that is 6 months before the
beginning of the plan year involved.
(C) Prohibition on federal funds for abortion services in
community health insurance option.--
(i) Determination by secretary.--The Secretary may not
determine, in accordance with subparagraph (A)(ii), that the
community health insurance option established under section
1323 shall provide coverage of services described in
subparagraph (B)(i) as part of benefits for the plan year
unless the Secretary--
(I) assures compliance with the requirements of paragraph
(2);
(II) assures, in accordance with applicable provisions of
generally accepted accounting requirements, circulars on
funds management of the Office of Management and Budget, and
guidance on accounting of the Government Accountability
Office, that no Federal funds are used for such coverage; and
(III) notwithstanding section 1323(e)(1)(C) or any other
provision of this title, takes all necessary steps to assure
that the United States does not bear the insurance risk for a
community health insurance option's coverage of services
described in subparagraph (B)(i).
(ii) State requirement.--If a State requires, in addition
to the essential health benefits required under section
1323(b)(3) (A), coverage of
[[Page H1935]]
services described in subparagraph (B)(i) for enrollees of a
community health insurance option offered in such State, the
State shall assure that no funds flowing through or from the
community health insurance option, and no other Federal
funds, pay or defray the cost of providing coverage of
services described in subparagraph (B)(i). The United States
shall not bear the insurance risk for a State's required
coverage of services described in subparagraph (B)(i).
(iii) Exceptions.--Nothing in this subparagraph shall apply
to coverage of services described in subparagraph (B)(ii) by
the community health insurance option. Services described in
subparagraph (B)(ii) shall be covered to the same extent as
such services are covered under title XIX of the Social
Security Act.
(D) Assured availability of varied coverage through
exchanges.--
(i) In general.--The Secretary shall assure that with
respect to qualified health plans offered in any Exchange
established pursuant to this title--
(I) there is at least one such plan that provides coverage
of services described in clauses (i) and (ii) of subparagraph
(B); and
(II) there is at least one such plan that does not provide
coverage of services described in subparagraph (B)(i).
(ii) Special rules.--For purposes of clause (i)--
(I) a plan shall be treated as described in clause (i)(II)
if the plan does not provide coverage of services described
in either subparagraph (B)(i) or (B)(ii); and
(II) if a State has one Exchange covering more than 1
insurance market, the Secretary shall meet the requirements
of clause (i) separately with respect to each such market.
(2) Prohibition on the use of federal funds.--
(A) In general.--If a qualified health plan provides
coverage of services described in paragraph (1)(B)(i), the
issuer of the plan shall not use any amount attributable to
any of the following for purposes of paying for such
services:
(i) The credit under section 36B of the Internal Revenue
Code of 1986 (and the amount (if any) of the advance payment
of the credit under section 1412 of the Patient Protection
and Affordable Care Act).
(ii) Any cost-sharing reduction under section 1402 of
thePatient Protection and Affordable Care Act (and the amount
(if any) of the advance payment of the reduction under
section 1412 of the Patient Protection and Affordable Care
Act).
(B) Segregation of funds.--In the case of a plan to which
subparagraph (A) applies, the issuer of the plan shall, out
of amounts not described in subparagraph (A), segregate an
amount equal to the actuarial amounts determined under
subparagraph (C) for all enrollees from the amounts described
in subparagraph (A).
(C) Actuarial value of optional service coverage.--
(i) In general.--The Secretary shall estimate the basic per
enrollee, per month cost, determined on an average actuarial
basis, for including coverage under a qualified health plan
of the services described in paragraph (1)(B)(i).
(ii) Considerations.--In making such estimate, the
Secretary--
(I) may take into account the impact on overall costs of
the inclusion of such coverage, but may not take into account
any cost reduction estimated to result from such services,
including prenatal care, delivery, or postnatal care;
(II) shall estimate such costs as if such coverage were
included for the entire population covered; and
(III) may not estimate such a cost at less than $1 per
enrollee, per month.
(3) Provider conscience protections.--No individual health
care provider or health care facility may be discriminated
against because of a willingness or an unwillingness, if
doing so is contrary to the religious or moral beliefs of the
provider or facility, to provide, pay for, provide coverage
of, or refer for abortions.
(b) Application of State and Federal Laws Regarding
Abortion.--
(1) No preemption of state laws regarding abortion.--
Nothing in this Act shall be construed to preempt or
otherwise have any effect on State laws regarding the
prohibition of (or requirement of) coverage, funding, or
procedural requirements on abortions, including parental
notification or consent for the performance of an abortion on
a minor.
(2) No effect on federal laws regarding abortion.--
(A) In general.--Nothing in this Act shall be construed to
have any effect on Federal laws regarding--
(i) conscience protection;
(ii) willingness or refusal to provide abortion; and
(iii) discrimination on the basis of the willingness or
refusal to provide, pay for, cover, or refer for abortion or
to provide or participate in training to provide abortion.
(3) No effect on federal civil rights law.--Nothing in this
subsection shall alter the rights and obligations of
employees and employers under title VII of the Civil Rights
Act of 1964.
(c) Application of Emergency Services Laws.--Nothing in
this Act shall be construed to relieve any health care
provider from providing emergency services as required by
State or Federal law, including section 1867 of the Social
Security Act (popularly known as ``EMTALA'').
SEC. 1304. RELATED DEFINITIONS.
(a) Definitions Relating to Markets.--In this title:
(1) Group market.--The term ``group market'' means the
health insurance market under which individuals obtain health
insurance coverage (directly or through any arrangement) on
behalf of themselves (and their dependents) through a group
health plan maintained by an employer.
(2) Individual market.--The term ``individual market''
means the market for health insurance coverage offered to
individuals other than in connection with a group health
plan.
(3) Large and small group markets.--The terms ``large group
market'' and ``small group market'' mean the health insurance
market under which individuals obtain health insurance
coverage (directly or through any arrangement) on behalf of
themselves (and their dependents) through a group health plan
maintained by a large employer (as defined in subsection
(b)(1)) or by a small employer (as defined in subsection
(b)(2)), respectively.
(b) Employers.--In this title:
(1) Large employer.--The term ``large employer'' means, in
connection with a group health plan with respect to a
calendar year and a plan year, an employer who employed an
average of at least 101 employees on business days during the
preceding calendar year and who employs at least 1 employee
on the first day of the plan year.
(2) Small employer.--The term ``small employer'' means, in
connection with a group health plan with respect to a
calendar year and a plan year, an employer who employed an
average of at least 1 but not more than 100 employees on
business days during the preceding calendar year and who
employs at least 1 employee on the first day of the plan
year.
(3) State option to treat 50 employees as small.--In the
case of plan years beginning before January 1, 2016, a State
may elect to apply this subsection by substituting ``51
employees'' for ``101 employees'' in paragraph (1) and by
substituting ``50 employees'' for ``100 employees'' in
paragraph (2).
(4) Rules for determining employer size.--For purposes of
this subsection--
(A) Application of aggregation rule for employers.--All
persons treated as a single employer under subsection (b),
(c), (m), or (o) of section 414 of the Internal Revenue Code
of 1986 shall be treated as 1 employer.
(B) Employers not in existence in preceding year.--In the
case of an employer which was not in existence throughout the
preceding calendar year, the determination of whether such
employer is a small or large employer shall be based on the
average number of employees that it is reasonably expected
such employer will employ on business days in the current
calendar year.
(C) Predecessors.--Any reference in this subsection to an
employer shall include a reference to any predecessor of such
employer.
(D) Continuation of participation for growing small
employers.--If--
(i) a qualified employer that is a small employer makes
enrollment in qualified health plans offered in the small
group market available to its employees through an Exchange;
and
(ii) the employer ceases to be a small employer by reason
of an increase in the number of employees of such employer;
the employer shall continue to be treated as a small employer
for purposes of this subtitle for the period beginning with
the increase and ending with the first day on which the
employer does not make such enrollment available to its
employees.
(c) Secretary.--In this title, the term ``Secretary'' means
the Secretary of Health and Human Services.
(d) State.--In this title, the term ``State'' means each of
the 50 States and the District of Columbia.
PART II--CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH
BENEFIT EXCHANGES
SEC. 1311. AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS.
(a) Assistance to States to Establish American Health
Benefit Exchanges.--
(1) Planning and establishment grants.--There shall be
appropriated to the Secretary, out of any moneys in the
Treasury not otherwise appropriated, an amount necessary to
enable the Secretary to make awards, not later than 1 year
after the date of enactment of this Act, to States in the
amount specified in paragraph (2) for the uses described in
paragraph (3).
(2) Amount specified.--For each fiscal year, the Secretary
shall determine the total amount that the Secretary will make
available to each State for grants under this subsection.
(3) Use of funds.--A State shall use amounts awarded under
this subsection for activities (including planning
activities) related to establishing an American Health
Benefit Exchange, as described in subsection (b).
(4) Renewability of grant.--
(A) In general.--Subject to subsection (d)(4), the
Secretary may renew a grant awarded under paragraph (1) if
the State recipient of such grant--
(i) is making progress, as determined by the Secretary,
toward--
(I) establishing an Exchange; and
(II) implementing the reforms described in subtitles A and
C (and the amendments made by such subtitles); and
(ii) is meeting such other benchmarks as the Secretary may
establish.
(B) Limitation.--No grant shall be awarded under this
subsection after January 1, 2015.
(5) Technical assistance to facilitate participation in
shop exchanges.--The Secretary shall provide technical
assistance to States to facilitate the participation of
qualified small businesses in such States in SHOP Exchanges.
(b) American Health Benefit Exchanges.--
(1) In general.--Each State shall, not later than January
1, 2014, establish an American Health Benefit Exchange
(referred to in this title as an ``Exchange'') for the State
that--
(A) facilitates the purchase of qualified health plans;
[[Page H1936]]
(B) provides for the establishment of a Small Business
Health Options Program (in this title referred to as a ``SHOP
Exchange'') that is designed to assist qualified employers in
the State who are small employers in facilitating the
enrollment of their employees in qualified health plans
offered in the small group market in the State; and
(C) meets the requirements of subsection (d).
(2) Merger of individual and shop exchanges.--A State may
elect to provide only one Exchange in the State for providing
both Exchange and SHOP Exchange services to both qualified
individuals and qualified small employers, but only if the
Exchange has adequate resources to assist such individuals
and employers.
(c) Responsibilities of the Secretary.--
(1) In general.--The Secretary shall, by regulation,
establish criteria for the certification of health plans as
qualified health plans. Such criteria shall require that, to
be certified, a plan shall, at a minimum--
(A) meet marketing requirements, and not employ marketing
practices or benefit designs that have the effect of
discouraging the enrollment in such plan by individuals with
significant health needs;
(B) ensure a sufficient choice of providers (in a manner
consistent with applicable network adequacy provisions under
section 2702(c) of the Public Health Service Act), and
provide information to enrollees and prospective enrollees on
the availability of in-network and out-of-network providers;
(C) include within health insurance plan networks those
essential community providers, where available, that serve
predominately low-income, medically-underserved individuals,
such as health care providers defined in section 340B(a)(4)
of the Public Health Service Act and providers described in
section 1927(c)(1)(D)(i)(IV) of the Social Security Act as
set forth by section 221 of Public Law 111-8, except that
nothing in this subparagraph shall be construed to require
any health plan to provide coverage for any specific medical
procedure;
(D)(i) be accredited with respect to local performance on
clinical quality measures such as the Healthcare
Effectiveness Data and Information Set, patient experience
ratings on a standardized Consumer Assessment of Healthcare
Providers and Systems survey, as well as consumer access,
utilization management, quality assurance, provider
credentialing, complaints and appeals, network adequacy and
access, and patient information programs by any entity
recognized by the Secretary for the accreditation of health
insurance issuers or plans (so long as any such entity has
transparent and rigorous methodological and scoring
criteria); or
(ii) receive such accreditation within a period established
by an Exchange for such accreditation that is applicable to
all qualified health plans;
(E) implement a quality improvement strategy described in
subsection (g)(1);
(F) utilize a uniform enrollment form that qualified
individuals and qualified employers may use (either
electronically or on paper) in enrolling in qualified health
plans offered through such Exchange, and that takes into
account criteria that the National Association of Insurance
Commissioners develops and submits to the Secretary;
(G) utilize the standard format established for presenting
health benefits plan options; and
(H) provide information to enrollees and prospective
enrollees, and to each Exchange in which the plan is offered,
on any quality measures for health plan performance endorsed
under section 399JJ of the Public Health Service Act, as
applicable.
(2) Rule of construction.--Nothing in paragraph (1)(C)
shall be construed to require a qualified health plan to
contract with a provider described in such paragraph if such
provider refuses to accept the generally applicable payment
rates of such plan.
(3) Rating system.--The Secretary shall develop a rating
system that would rate qualified health plans offered through
an Exchange in each benefits level on the basis of the
relative quality and price. The Exchange shall include the
quality rating in the information provided to individuals and
employers through the Internet portal established under
paragraph (4).
(4) Enrollee satisfaction system.--The Secretary shall
develop an enrollee satisfaction survey system that would
evaluate the level of enrollee satisfaction with qualified
health plans offered through an Exchange, for each such
qualified health plan that had more than 500 enrollees in the
previous year. The Exchange shall include enrollee
satisfaction information in the information provided to
individuals and employers through the Internet portal
established under paragraph (5) in a manner that allows
individuals to easily compare enrollee satisfaction levels
between comparable plans.
(5) Internet portals.--The Secretary shall--
(A) continue to operate, maintain, and update the Internet
portal developed under section 1103(a) and to assist States
in developing and maintaining their own such portal; and
(B) make available for use by Exchanges a model template
for an Internet portal that may be used to direct qualified
individuals and qualified employers to qualified health
plans, to assist such individuals and employers in
determining whether they are eligible to participate in an
Exchange or eligible for a premium tax credit or cost-sharing
reduction, and to present standardized information (including
quality ratings) regarding qualified health plans offered
through an Exchange to assist consumers in making easy health
insurance choices.
Such template shall include, with respect to each qualified
health plan offered through the Exchange in each rating area,
access to the uniform outline of coverage the plan is
required to provide under section 2716 of the Public Health
Service Act and to a copy of the plan's written policy.
(6) Enrollment periods.--The Secretary shall require an
Exchange to provide for--
(A) an initial open enrollment, as determined by the
Secretary (such determination to be made not later than July
1, 2012);
(B) annual open enrollment periods, as determined by the
Secretary for calendar years after the initial enrollment
period;
(C) special enrollment periods specified in section 9801 of
the Internal Revenue Code of 1986 and other special
enrollment periods under circumstances similar to such
periods under part D of title XVIII of the Social Security
Act; and
(D) special monthly enrollment periods for Indians (as
defined in section 4 of the Indian Health Care Improvement
Act).
(d) Requirements.--
(1) In general.--An Exchange shall be a governmental agency
or nonprofit entity that is established by a State.
(2) Offering of coverage.--
(A) In general.--An Exchange shall make available qualified
health plans to qualified individuals and qualified
employers.
(B) Limitation.--
(i) In general.--An Exchange may not make available any
health plan that is not a qualified health plan.
(ii) Offering of stand-alone dental benefits.--Each
Exchange within a State shall allow an issuer of a plan that
only provides limited scope dental benefits meeting the
requirements of section 9832(c)(2)(A) of the Internal Revenue
Code of 1986 to offer the plan through the Exchange (either
separately or in conjunction with a qualified health plan) if
the plan provides pediatric dental benefits meeting the
requirements of section 1302(b)(1)(J)).
(3) Rules relating to additional required benefits.--
(A) In general.--Except as provided in subparagraph (B), an
Exchange may make available a qualified health plan
notwithstanding any provision of law that may require
benefits other than the essential health benefits specified
under section 1302(b).
(B) States may require additional benefits.--
(i) In general.--Subject to the requirements of clause
(ii), a State may require that a qualified health plan
offered in such State offer benefits in addition to the
essential health benefits specified under section 1302(b).
(ii) State must assume cost.--A State shall make payments
to or on behalf of an individual eligible for the premium tax
credit under section 36B of the Internal Revenue Code of 1986
and any cost-sharing reduction under section 1402 to defray
the cost to the individual of any additional benefits
described in clause (i) which are not eligible for such
credit or reduction under section 36B(b)(3)(D) of such Code
and section 1402(c)(4).
(4) Functions.--An Exchange shall, at a minimum--
(A) implement procedures for the certification,
recertification, and decertification, consistent with
guidelines developed by the Secretary under subsection (c),
of health plans as qualified health plans;
(B) provide for the operation of a toll-free telephone
hotline to respond to requests for assistance;
(C) maintain an Internet website through which enrollees
and prospective enrollees of qualified health plans may
obtain standardized comparative information on such plans;
(D) assign a rating to each qualified health plan offered
through such Exchange in accordance with the criteria
developed by the Secretary under subsection (c)(3);
(E) utilize a standardized format for presenting health
benefits plan options in the Exchange, including the use of
the uniform outline of coverage established under section
2715 of the Public Health Service Act;
(F) in accordance with section 1413, inform individuals of
eligibility requirements for the medicaid program under title
XIX of the Social Security Act, the CHIP program under title
XXI of such Act, or any applicable State or local public
program and if through screening of the application by the
Exchange, the Exchange determines that such individuals are
eligible for any such program, enroll such individuals in
such program;
(G) establish and make available by electronic means a
calculator to determine the actual cost of coverage after the
application of any premium tax credit under section 36B of
the Internal Revenue Code of 1986 and any cost-sharing
reduction under section 1402;
(H) subject to section 1411, grant a certification
attesting that, for purposes of the individual responsibility
penalty under section 5000A of the Internal Revenue Code of
1986, an individual is exempt from the individual requirement
or from the penalty imposed by such section because--
(i) there is no affordable qualified health plan available
through the Exchange, or the individual's employer, covering
the individual; or
(ii) the individual meets the requirements for any other
such exemption from the individual responsibility requirement
or penalty;
(I) transfer to the Secretary of the Treasury--
(i) a list of the individuals who are issued a
certification under subparagraph (H), including the name and
taxpayer identification number of each individual;
(ii) the name and taxpayer identification number of each
individual who was an employee of an employer but who was
determined to be eligible for the premium tax credit under
section 36B of the Internal Revenue Code of 1986 because--
(I) the employer did not provide minimum essential
coverage; or
(II) the employer provided such minimum essential coverage
but it was determined under
[[Page H1937]]
section 36B(c)(2)(C) of such Code to either be unaffordable
to the employee or not provide the required minimum actuarial
value; and
(iii) the name and taxpayer identification number of each
individual who notifies the Exchange under section 1411(b)(4)
that they have changed employers and of each individual who
ceases coverage under a qualified health plan during a plan
year (and the effective date of such cessation);
(J) provide to each employer the name of each employee of
the employer described in subparagraph (I)(ii) who ceases
coverage under a qualified health plan during a plan year
(and the effective date of such cessation); and
(K) establish the Navigator program described in subsection
(i).
(5) Funding limitations.--
(A) No federal funds for continued operations.--In
establishing an Exchange under this section, the State shall
ensure that such Exchange is self-sustaining beginning on
January 1, 2015, including allowing the Exchange to charge
assessments or user fees to participating health insurance
issuers, or to otherwise generate funding, to support its
operations.
(B) Prohibiting wasteful use of funds.--In carrying out
activities under this subsection, an Exchange shall not
utilize any funds intended for the administrative and
operational expenses of the Exchange for staff retreats,
promotional giveaways, excessive executive compensation, or
promotion of Federal or State legislative and regulatory
modifications.
(6) Consultation.--An Exchange shall consult with
stakeholders relevant to carrying out the activities under
this section, including--
(A) health care consumers who are enrollees in qualified
health plans;
(B) individuals and entities with experience in
facilitating enrollment in qualified health plans;
(C) representatives of small businesses and self-employed
individuals;
(D) State Medicaid offices; and
(E) advocates for enrolling hard to reach populations.
(7) Publication of costs.--An Exchange shall publish the
average costs of licensing, regulatory fees, and any other
payments required by the Exchange, and the administrative
costs of such Exchange, on an Internet website to educate
consumers on such costs. Such information shall also include
monies lost to waste, fraud, and abuse.
(e) Certification.--
(1) In general.--An Exchange may certify a health plan as a
qualified health plan if--
(A) such health plan meets the requirements for
certification as promulgated by the Secretary under
subsection (c)(1); and
(B) the Exchange determines that making available such
health plan through such Exchange is in the interests of
qualified individuals and qualified employers in the State or
States in which such Exchange operates, except that the
Exchange may not exclude a health plan--
(i) on the basis that such plan is a fee-for-service plan;
(ii) through the imposition of premium price controls; or
(iii) on the basis that the plan provides treatments
necessary to prevent patients' deaths in circumstances the
Exchange determines are inappropriate or too costly.
(2) Premium considerations.--The Exchange shall require
health plans seeking certification as qualified health plans
to submit a justification for any premium increase prior to
implementation of the increase. Such plans shall prominently
post such information on their websites. The Exchange may
take this information, and the information and the
recommendations provided to the Exchange by the State under
section 2794(b)(1) of the Public Health Service Act (relating
to patterns or practices of excessive or unjustified premium
increases), into consideration when determining whether to
make such health plan available through the Exchange. The
Exchange shall take into account any excess of premium growth
outside the Exchange as compared to the rate of such growth
inside the Exchange, including information reported by the
States.
(f) Flexibility.--
(1) Regional or other interstate exchanges.--An Exchange
may operate in more than one State if--
(A) each State in which such Exchange operates permits such
operation; and
(B) the Secretary approves such regional or interstate
Exchange.
(2) Subsidiary exchanges.--A State may establish one or
more subsidiary Exchanges if--
(A) each such Exchange serves a geographically distinct
area; and
(B) the area served by each such Exchange is at least as
large as a rating area described in section 2701(a) of the
Public Health Service Act.
(3) Authority to contract.--
(A) In general.--A State may elect to authorize an Exchange
established by the State under this section to enter into an
agreement with an eligible entity to carry out 1 or more
responsibilities of the Exchange.
(B) Eligible entity.--In this paragraph, the term
``eligible entity'' means--
(i) a person--
(I) incorporated under, and subject to the laws of, 1 or
more States;
(II) that has demonstrated experience on a State or
regional basis in the individual and small group health
insurance markets and in benefits coverage; and
(III) that is not a health insurance issuer or that is
treated under subsection (a) or (b) of section 52 of the
Internal Revenue Code of 1986 as a member of the same
controlled group of corporations (or under common control
with) as a health insurance issuer; or
(ii) the State medicaid agency under title XIX of the
Social Security Act.
(g) Rewarding Quality Through Market-Based Incentives.--
(1) Strategy described.--A strategy described in this
paragraph is a payment structure that provides increased
reimbursement or other incentives for--
(A) improving health outcomes through the implementation of
activities that shall include quality reporting, effective
case management, care coordination, chronic disease
management, medication and care compliance initiatives,
including through the use of the medical home model, for
treatment or services under the plan or coverage;
(B) the implementation of activities to prevent hospital
readmissions through a comprehensive program for hospital
discharge that includes patient-centered education and
counseling, comprehensive discharge planning, and post
discharge reinforcement by an appropriate health care
professional;
(C) the implementation of activities to improve patient
safety and reduce medical errors through the appropriate use
of best clinical practices, evidence based medicine, and
health information technology under the plan or coverage; and
(D) the implementation of wellness and health promotion
activities.
(2) Guidelines.--The Secretary, in consultation with
experts in health care quality and stakeholders, shall
develop guidelines concerning the matters described in
paragraph (1).
(3) Requirements.--The guidelines developed under paragraph
(2) shall require the periodic reporting to the applicable
Exchange of the activities that a qualified health plan has
conducted to implement a strategy described in paragraph (1).
(h) Quality Improvement.--
(1) Enhancing patient safety.--Beginning on January 1,
2015, a qualified health plan may contract with--
(A) a hospital with greater than 50 beds only if such
hospital--
(i) utilizes a patient safety evaluation system as
described in part C of title IX of the Public Health Service
Act; and
(ii) implements a mechanism to ensure that each patient
receives a comprehensive program for hospital discharge that
includes patient-centered education and counseling,
comprehensive discharge planning, and post discharge
reinforcement by an appropriate health care professional; or
(B) a health care provider only if such provider implements
such mechanisms to improve health care quality as the
Secretary may by regulation require.
(2) Exceptions.--The Secretary may establish reasonable
exceptions to the requirements described in paragraph (1).
(3) Adjustment.--The Secretary may by regulation adjust the
number of beds described in paragraph (1)(A).
(i) Navigators.--
(1) In general.--An Exchange shall establish a program
under which it awards grants to entities described in
paragraph (2) to carry out the duties described in paragraph
(3).
(2) Eligibility.--
(A) In general.--To be eligible to receive a grant under
paragraph (1), an entity shall demonstrate to the Exchange
involved that the entity has existing relationships, or could
readily establish relationships, with employers and
employees, consumers (including uninsured and underinsured
consumers), or self-employed individuals likely to be
qualified to enroll in a qualified health plan.
(B) Types.--Entities described in subparagraph (A) may
include trade, industry, and professional associations,
commercial fishing industry organizations, ranching and
farming organizations, community and consumer-focused
nonprofit groups, chambers of commerce, unions, small
business development centers, other licensed insurance agents
and brokers, and other entities that--
(i) are capable of carrying out the duties described in
paragraph (3);
(ii) meet the standards described in paragraph (4); and
(iii) provide information consistent with the standards
developed under paragraph (5).
(3) Duties.--An entity that serves as a navigator under a
grant under this subsection shall--
(A) conduct public education activities to raise awareness
of the availability of qualified health plans;
(B) distribute fair and impartial information concerning
enrollment in qualified health plans, and the availability of
premium tax credits under section 36B of the Internal Revenue
Code of 1986 and cost-sharing reductions under section 1402;
(C) facilitate enrollment in qualified health plans;
(D) provide referrals to any applicable office of health
insurance consumer assistance or health insurance ombudsman
established under section 2793 of the Public Health Service
Act, or any other appropriate State agency or agencies, for
any enrollee with a grievance, complaint, or question
regarding their health plan, coverage, or a determination
under such plan or coverage; and
(E) provide information in a manner that is culturally and
linguistically appropriate to the needs of the population
being served by the Exchange or Exchanges.
(4) Standards.--
(A) In general.--The Secretary shall establish standards
for navigators under this subsection, including provisions to
ensure that any private or public entity that is selected as
a navigator is qualified, and licensed if appropriate, to
engage in the navigator activities described in this
subsection and to avoid conflicts of interest. Under such
standards, a navigator shall not--
(i) be a health insurance issuer; or
[[Page H1938]]
(ii) receive any consideration directly or indirectly from
any health insurance issuer in connection with the enrollment
of any qualified individuals or employees of a qualified
employer in a qualified health plan.
(5) Fair and impartial information and services.--The
Secretary, in collaboration with States, shall develop
standards to ensure that information made available by
navigators is fair, accurate, and impartial.
(6) Funding.--Grants under this subsection shall be made
from the operational funds of the Exchange and not Federal
funds received by the State to establish the Exchange.
(j) Applicability of Mental Health Parity.--Section 2726 of
the Public Health Service Act shall apply to qualified health
plans in the same manner and to the same extent as such
section applies to health insurance issuers and group health
plans.
(k) Conflict.--An Exchange may not establish rules that
conflict with or prevent the application of regulations
promulgated by the Secretary under this subtitle.
SEC. 1312. CONSUMER CHOICE.
(a) Choice.--
(1) Qualified individuals.--A qualified individual may
enroll in any qualified health plan available to such
individual.
(2) Qualified employers.--
(A) Employer may specify level.--A qualified employer may
provide support for coverage of employees under a qualified
health plan by selecting any level of coverage under section
1302(d) to be made available to employees through an
Exchange.
(B) Employee may choose plans within a level.--Each
employee of a qualified employer that elects a level of
coverage under subparagraph (A) may choose to enroll in a
qualified health plan that offers coverage at that level.
(b) Payment of Premiums by Qualified Individuals.--A
qualified individual enrolled in any qualified health plan
may pay any applicable premium owed by such individual to the
health insurance issuer issuing such qualified health plan.
(c) Single Risk Pool.--
(1) Individual market.--A health insurance issuer shall
consider all enrollees in all health plans (other than
grandfathered health plans) offered by such issuer in the
individual market, including those enrollees who do not
enroll in such plans through the Exchange, to be members of a
single risk pool.
(2) Small group market.--A health insurance issuer shall
consider all enrollees in all health plans (other than
grandfathered health plans) offered by such issuer in the
small group market, including those enrollees who do not
enroll in such plans through the Exchange, to be members of a
single risk pool.
(3) Merger of markets.--A State may require the individual
and small group insurance markets within a State to be merged
if the State determines appropriate.
(4) State law.--A State law requiring grandfathered health
plans to be included in a pool described in paragraph (1) or
(2) shall not apply.
(d) Empowering Consumer Choice.--
(1) Continued operation of market outside exchanges.--
Nothing in this title shall be construed to prohibit--
(A) a health insurance issuer from offering outside of an
Exchange a health plan to a qualified individual or qualified
employer; and
(B) a qualified individual from enrolling in, or a
qualified employer from selecting for its employees, a health
plan offered outside of an Exchange.
(2) Continued operation of state benefit requirements.--
Nothing in this title shall be construed to terminate,
abridge, or limit the operation of any requirement under
State law with respect to any policy or plan that is offered
outside of an Exchange to offer benefits.
(3) Voluntary nature of an exchange.--
(A) Choice to enroll or not to enroll.--Nothing in this
title shall be construed to restrict the choice of a
qualified individual to enroll or not to enroll in a
qualified health plan or to participate in an Exchange.
(B) Prohibition against compelled enrollment.--Nothing in
this title shall be construed to compel an individual to
enroll in a qualified health plan or to participate in an
Exchange.
(C) Individuals allowed to enroll in any plan.--A qualified
individual may enroll in any qualified health plan, except
that in the case of a catastrophic plan described in section
1302(e), a qualified individual may enroll in the plan only
if the individual is eligible to enroll in the plan under
section 1302(e)(2).
(D) Members of congress in the exchange.--
(i) Requirement.--Notwithstanding any other provision of
law, after the effective date of this subtitle, the only
health plans that the Federal Government may make available
to Members of Congress and congressional staff with respect
to their service as a Member of Congress or congressional
staff shall be health plans that are--
(I) created under this Act (or an amendment made by this
Act); or
(II) offered through an Exchange established under this Act
(or an amendment made by this Act).
(ii) Definitions.--In this section:
(I) Member of congress.--The term ``Member of Congress''
means any member of the House of Representatives or the
Senate.
(II) Congressional staff.--The term ``congressional staff''
means all full-time and part-time employees employed by the
official office of a Member of Congress, whether in
Washington, DC or outside of Washington, DC.
(4) No penalty for transferring to minimum essential
coverage outside exchange.--An Exchange, or a qualified
health plan offered through an Exchange, shall not impose any
penalty or other fee on an individual who cancels enrollment
in a plan because the individual becomes eligible for minimum
essential coverage (as defined in section 5000A(f) of the
Internal Revenue Code of 1986 without regard to paragraph
(1)(C) or (D) thereof) or such coverage becomes affordable
(within the meaning of section 36B(c)(2)(C) of such Code).
(e) Enrollment Through Agents or Brokers.--The Secretary
shall establish procedures under which a State may allow
agents or brokers--
(1) to enroll individuals in any qualified health plans in
the individual or small group market as soon as the plan is
offered through an Exchange in the State; and
(2) to assist individuals in applying for premium tax
credits and cost-sharing reductions for plans sold through an
Exchange.
Such procedures may include the establishment of rate
schedules for broker commissions paid by health benefits
plans offered through an exchange.
(f) Qualified Individuals and Employers; Access Limited to
Citizens and Lawful Residents.--
(1) Qualified individuals.--In this title:
(A) In general.--The term ``qualified individual'' means,
with respect to an Exchange, an individual who--
(i) is seeking to enroll in a qualified health plan in the
individual market offered through the Exchange; and
(ii) resides in the State that established the Exchange
(except with respect to territorial agreements under section
1312(f)).
(B) Incarcerated individuals excluded.--An individual shall
not be treated as a qualified individual if, at the time of
enrollment, the individual is incarcerated, other than
incarceration pending the disposition of charges.
(2) Qualified employer.--In this title:
(A) In general.--The term ``qualified employer'' means a
small employer that elects to make all full-time employees of
such employer eligible for 1 or more qualified health plans
offered in the small group market through an Exchange that
offers qualified health plans.
(B) Extension to large groups.--
(i) In general.--Beginning in 2017, each State may allow
issuers of health insurance coverage in the large group
market in the State to offer qualified health plans in such
market through an Exchange. Nothing in this subparagraph
shall be construed as requiring the issuer to offer such
plans through an Exchange.
(ii) Large employers eligible.--If a State under clause (i)
allows issuers to offer qualified health plans in the large
group market through an Exchange, the term ``qualified
employer'' shall include a large employer that elects to make
all full-time employees of such employer eligible for 1 or
more qualified health plans offered in the large group market
through the Exchange.
(3) Access limited to lawful residents.--If an individual
is not, or is not reasonably expected to be for the entire
period for which enrollment is sought, a citizen or national
of the United States or an alien lawfully present in the
United States, the individual shall not be treated as a
qualified individual and may not be covered under a qualified
health plan in the individual market that is offered through
an Exchange.
SEC. 1313. FINANCIAL INTEGRITY.
(a) Accounting for Expenditures.--
(1) In general.--An Exchange shall keep an accurate
accounting of all activities, receipts, and expenditures and
shall annually submit to the Secretary a report concerning
such accountings.
(2) Investigations.--The Secretary, in coordination with
the Inspector General of the Department of Health and Human
Services, may investigate the affairs of an Exchange, may
examine the properties and records of an Exchange, and may
require periodic reports in relation to activities undertaken
by an Exchange. An Exchange shall fully cooperate in any
investigation conducted under this paragraph.
(3) Audits.--An Exchange shall be subject to annual audits
by the Secretary.
(4) Pattern of abuse.--If the Secretary determines that an
Exchange or a State has engaged in serious misconduct with
respect to compliance with the requirements of, or carrying
out of activities required under, this title, the Secretary
may rescind from payments otherwise due to such State
involved under this or any other Act administered by the
Secretary an amount not to exceed 1 percent of such payments
per year until corrective actions are taken by the State that
are determined to be adequate by the Secretary.
(5) Protections against fraud and abuse.--With respect to
activities carried out under this title, the Secretary shall
provide for the efficient and non-discriminatory
administration of Exchange activities and implement any
measure or procedure that--
(A) the Secretary determines is appropriate to reduce fraud
and abuse in the administration of this title; and
(B) the Secretary has authority to implement under this
title or any other Act.
(6) Application of the false claims act.--
(A) In general.--Payments made by, through, or in
connection with an Exchange are subject to the False Claims
Act (31 U.S.C. 3729 et seq.) if those payments include any
Federal funds. Compliance with the requirements of this Act
concerning eligibility for a health insurance issuer to
participate in the Exchange shall be a material condition of
an issuer's entitlement to receive payments, including
payments of premium tax credits and cost-sharing reductions,
through the Exchange.
(B) Damages.--Notwithstanding paragraph (1) of section
3729(a) of title 31, United States
[[Page H1939]]
Code, and subject to paragraph (2) of such section, the civil
penalty assessed under the False Claims Act on any person
found liable under such Act as described in subparagraph (A)
shall be increased by not less than 3 times and not more than
6 times the amount of damages which the Government sustains
because of the act of that person.
(b) GAO Oversight.--Not later than 5 years after the first
date on which Exchanges are required to be operational under
this title, the Comptroller General shall conduct an ongoing
study of Exchange activities and the enrollees in qualified
health plans offered through Exchanges. Such study shall
review--
(1) the operations and administration of Exchanges,
including surveys and reports of qualified health plans
offered through Exchanges and on the experience of such plans
(including data on enrollees in Exchanges and individuals
purchasing health insurance coverage outside of Exchanges),
the expenses of Exchanges, claims statistics relating to
qualified health plans, complaints data relating to such
plans, and the manner in which Exchanges meet their goals;
(2) any significant observations regarding the utilization
and adoption of Exchanges;
(3) where appropriate, recommendations for improvements in
the operations or policies of Exchanges; and
(4) how many physicians, by area and specialty, are not
taking or accepting new patients enrolled in Federal
Government health care programs, and the adequacy of provider
networks of Federal Government health care programs.
PART III--STATE FLEXIBILITY RELATING TO EXCHANGES
SEC. 1321. STATE FLEXIBILITY IN OPERATION AND ENFORCEMENT OF
EXCHANGES AND RELATED REQUIREMENTS.
(a) Establishment of Standards.--
(1) In general.--The Secretary shall, as soon as
practicable after the date of enactment of this Act, issue
regulations setting standards for meeting the requirements
under this title, and the amendments made by this title, with
respect to--
(A) the establishment and operation of Exchanges (including
SHOP Exchanges);
(B) the offering of qualified health plans through such
Exchanges;
(C) the establishment of the reinsurance and risk
adjustment programs under part V; and
(D) such other requirements as the Secretary determines
appropriate.
The preceding sentence shall not apply to standards for
requirements under subtitles A and C (and the amendments made
by such subtitles) for which the Secretary issues regulations
under the Public Health Service Act.
(2) Consultation.--In issuing the regulations under
paragraph (1), the Secretary shall consult with the National
Association of Insurance Commissioners and its members and
with health insurance issuers, consumer organizations, and
such other individuals as the Secretary selects in a manner
designed to ensure balanced representation among interested
parties.
(b) State Action.--Each State that elects, at such time and
in such manner as the Secretary may prescribe, to apply the
requirements described in subsection (a) shall, not later
than January 1, 2014, adopt and have in effect--
(1) the Federal standards established under subsection (a);
or
(2) a State law or regulation that the Secretary determines
implements the standards within the State.
(c) Failure To Establish Exchange or Implement
Requirements.--
(1) In general.--If--
(A) a State is not an electing State under subsection (b);
or
(B) the Secretary determines, on or before January 1, 2013,
that an electing State--
(i) will not have any required Exchange operational by
January 1, 2014; or
(ii) has not taken the actions the Secretary determines
necessary to implement--
(I) the other requirements set forth in the standards under
subsection (a); or
(II) the requirements set forth in subtitles A and C and
the amendments made by such subtitles;
the Secretary shall (directly or through agreement with a
not-for-profit entity) establish and operate such Exchange
within the State and the Secretary shall take such actions as
are necessary to implement such other requirements.
(2) Enforcement authority.--The provisions of section
2736(b) of the Public Health Services Act shall apply to the
enforcement under paragraph (1) of requirements of subsection
(a)(1) (without regard to any limitation on the application
of those provisions to group health plans).
(d) No Interference With State Regulatory Authority.--
Nothing in this title shall be construed to preempt any State
law that does not prevent the application of the provisions
of this title.
(e) Presumption for Certain State-Operated Exchanges.--
(1) In general.--In the case of a State operating an
Exchange before January 1, 2010, and which has insured a
percentage of its population not less than the percentage of
the population projected to be covered nationally after the
implementation of this Act, that seeks to operate an Exchange
under this section, the Secretary shall presume that such
Exchange meets the standards under this section unless the
Secretary determines, after completion of the process
established under paragraph (2), that the Exchange does not
comply with such standards.
(2) Process.--The Secretary shall establish a process to
work with a State described in paragraph (1) to provide
assistance necessary to assist the State's Exchange in coming
into compliance with the standards for approval under this
section.
SEC. 1322. FEDERAL PROGRAM TO ASSIST ESTABLISHMENT AND
OPERATION OF NONPROFIT, MEMBER-RUN HEALTH
INSURANCE ISSUERS.
(a) Establishment of Program.--
(1) In general.--The Secretary shall establish a program to
carry out the purposes of this section to be known as the
Consumer Operated and Oriented Plan (CO-OP) program.
(2) Purpose.--It is the purpose of the CO-OP program to
foster the creation of qualified nonprofit health insurance
issuers to offer qualified health plans in the individual and
small group markets in the States in which the issuers are
licensed to offer such plans.
(b) Loans and Grants Under the CO-OP Program.--
(1) In general.--The Secretary shall provide through the
CO-OP program for the awarding to persons applying to become
qualified nonprofit health insurance issuers of--
(A) loans to provide assistance to such person in meeting
its start-up costs; and
(B) grants to provide assistance to such person in meeting
any solvency requirements of States in which the person seeks
to be licensed to issue qualified health plans.
(2) Requirements for awarding loans and grants.--
(A) In general.--In awarding loans and grants under the CO-
OP program, the Secretary shall--
(i) take into account the recommendations of the advisory
board established under paragraph (3);
(ii) give priority to applicants that will offer qualified
health plans on a Statewide basis, will utilize integrated
care models, and have significant private support; and
(iii) ensure that there is sufficient funding to establish
at least 1 qualified nonprofit health insurance issuer in
each State, except that nothing in this clause shall prohibit
the Secretary from funding the establishment of multiple
qualified nonprofit health insurance issuers in any State if
the funding is sufficient to do so.
(B) States without issuers in program.--If no health
insurance issuer applies to be a qualified nonprofit health
insurance issuer within a State, the Secretary may use
amounts appropriated under this section for the awarding of
grants to encourage the establishment of a qualified
nonprofit health insurance issuer within the State or the
expansion of a qualified nonprofit health insurance issuer
from another State to the State.
(C) Agreement.--
(i) In general.--The Secretary shall require any person
receiving a loan or grant under the CO-OP program to enter
into an agreement with the Secretary which requires such
person to meet (and to continue to meet)--
(I) any requirement under this section for such person to
be treated as a qualified nonprofit health insurance issuer;
and
(II) any requirements contained in the agreement for such
person to receive such loan or grant.
(ii) Restrictions on use of federal funds.--The agreement
shall include a requirement that no portion of the funds made
available by any loan or grant under this section may be
used--
(I) for carrying on propaganda, or otherwise attempting, to
influence legislation; or
(II) for marketing.
Nothing in this clause shall be construed to allow a person
to take any action prohibited by section 501(c)(29) of the
Internal Revenue Code of 1986.
(iii) Failure to meet requirements.--If the Secretary
determines that a person has failed to meet any requirement
described in clause (i) or (ii) and has failed to correct
such failure within a reasonable period of time of when the
person first knows (or reasonably should have known) of such
failure, such person shall repay to the Secretary an amount
equal to the sum of--
(I) 110 percent of the aggregate amount of loans and grants
received under this section; plus
(II) interest on the aggregate amount of loans and grants
received under this section for the period the loans or
grants were outstanding.
The Secretary shall notify the Secretary of the Treasury of
any determination under this section of a failure that
results in the termination of an issuer's tax-exempt status
under section 501(c)(29) of such Code.
(D) Time for awarding loans and grants.--The Secretary
shall not later than July 1, 2013, award the loans and grants
under the CO-OP program and begin the distribution of amounts
awarded under such loans and grants.
(3) Advisory board.--
(A) In general.--The advisory board under this paragraph
shall consist of 15 members appointed by the Comptroller
General of the United States from among individuals with
qualifications described in section 1805(c)(2) of the Social
Security Act.
(B) Rules relating to appointments.--
(i) Standards.--Any individual appointed under subparagraph
(A) shall meet ethics and conflict of interest standards
protecting against insurance industry involvement and
interference.
(ii) Original appointments.--The original appointment of
board members under subparagraph (A)(ii) shall be made no
later than 3 months after the date of enactment of this Act.
(C) Vacancy.--Any vacancy on the advisory board shall be
filled in the same manner as the original appointment.
(D) Pay and reimbursement.--
(i) No compensation for members of advisory board.--Except
as provided in clause (ii), a member of the advisory board
may not receive pay, allowances, or benefits by reason of
their service on the board.
(ii) Travel expenses.--Each member shall receive travel
expenses, including per diem in lieu
[[Page H1940]]
of subsistence under subchapter I of chapter 57 of title 5,
United States Code.
(E) Application of faca.--The Federal Advisory Committee
Act (5 U.S.C. App.) shall apply to the advisory board, except
that section 14 of such Act shall not apply.
(F) Termination.--The advisory board shall terminate on the
earlier of the date that it completes its duties under this
section or December 31, 2015.
(c) Qualified Nonprofit Health Insurance Issuer.--For
purposes of this section--
(1) In general.--The term ``qualified nonprofit health
insurance issuer'' means a health insurance issuer that is an
organization--
(A) that is organized under State law as a nonprofit,
member corporation;
(B) substantially all of the activities of which consist of
the issuance of qualified health plans in the individual and
small group markets in each State in which it is licensed to
issue such plans; and
(C) that meets the other requirements of this subsection.
(2) Certain organizations prohibited.--An organization
shall not be treated as a qualified nonprofit health
insurance issuer if--
(A) the organization or a related entity (or any
predecessor of either) was a health insurance issuer on July
16, 2009; or
(B) the organization is sponsored by a State or local
government, any political subdivision thereof, or any
instrumentality of such government or political subdivision.
(3) Governance requirements.--An organization shall not be
treated as a qualified nonprofit health insurance issuer
unless--
(A) the governance of the organization is subject to a
majority vote of its members;
(B) its governing documents incorporate ethics and conflict
of interest standards protecting against insurance industry
involvement and interference; and
(C) as provided in regulations promulgated by the
Secretary, the organization is required to operate with a
strong consumer focus, including timeliness, responsiveness,
and accountability to members.
(4) Profits inure to benefit of members.--An organization
shall not be treated as a qualified nonprofit health
insurance issuer unless any profits made by the organization
are required to be used to lower premiums, to improve
benefits, or for other programs intended to improve the
quality of health care delivered to its members.
(5) Compliance with state insurance laws.--An organization
shall not be treated as a qualified nonprofit health
insurance issuer unless the organization meets all the
requirements that other issuers of qualified health plans are
required to meet in any State where the issuer offers a
qualified health plan, including solvency and licensure
requirements, rules on payments to providers, and compliance
with network adequacy rules, rate and form filing rules, any
applicable State premium assessments and any other State law
described in section 1324(b).
(6) Coordination with state insurance reforms.--An
organization shall not be treated as a qualified nonprofit
health insurance issuer unless the organization does not
offer a health plan in a State until that State has in effect
(or the Secretary has implemented for the State) the market
reforms required by part A of title XXVII of the Public
Health Service Act (as amended by subtitles A and C of this
Act).
(d) Establishment of Private Purchasing Council.--
(1) In general.--Qualified nonprofit health insurance
issuers participating in the CO-OP program under this section
may establish a private purchasing council to enter into
collective purchasing arrangements for items and services
that increase administrative and other cost efficiencies,
including claims administration, administrative services,
health information technology, and actuarial services.
(2) Council may not set payment rates.--The private
purchasing council established under paragraph (1) shall not
set payment rates for health care facilities or providers
participating in health insurance coverage provided by
qualified nonprofit health insurance issuers.
(3) Continued application of antitrust laws.--
(A) In general.--Nothing in this section shall be construed
to limit the application of the antitrust laws to any private
purchasing council (whether or not established under this
subsection) or to any qualified nonprofit health insurance
issuer participating in such a council.
(B) Antitrust laws.--For purposes of this subparagraph, the
term ``antitrust laws'' has the meaning given the term in
subsection (a) of the first section of the Clayton Act (15
U.S.C. 12(a)). Such term also includes section 5 of the
Federal Trade Commission Act (15 U.S.C. 45) to the extent
that such section 5 applies to unfair methods of competition.
(e) Limitation on Participation.--No representative of any
Federal, State, or local government (or of any political
subdivision or instrumentality thereof), and no
representative of a person described in subsection (c)(2)(A),
may serve on the board of directors of a qualified nonprofit
health insurance issuer or with a private purchasing council
established under subsection (d).
(f) Limitations on Secretary.--
(1) In general.--The Secretary shall not--
(A) participate in any negotiations between 1 or more
qualified nonprofit health insurance issuers (or a private
purchasing council established under subsection (d)) and any
health care facilities or providers, including any drug
manufacturer, pharmacy, or hospital; and
(B) establish or maintain a price structure for
reimbursement of any health benefits covered by such issuers.
(2) Competition.--Nothing in this section shall be
construed as authorizing the Secretary to interfere with the
competitive nature of providing health benefits through
qualified nonprofit health insurance issuers.
(g) Appropriations.--There are hereby appropriated, out of
any funds in the Treasury not otherwise appropriated,
$6,000,000,000 to carry out this section.
(h) Tax Exemption for Qualified Nonprofit Health Insurance
Issuer.--
(1) In general.--Section 501(c) of the Internal Revenue
Code of 1986 (relating to list of exempt organizations) is
amended by adding at the end the following:
``(29) CO-OP health insurance issuers.--
``(A) In general.--A qualified nonprofit health insurance
issuer (within the meaning of section 1322 of the Patient
Protection and Affordable Care Act) which has received a loan
or grant under the CO-OP program under such section, but only
with respect to periods for which the issuer is in compliance
with the requirements of such section and any agreement with
respect to the loan or grant.
``(B) Conditions for exemption.--Subparagraph (A) shall
apply to an organization only if--
``(i) the organization has given notice to the Secretary,
in such manner as the Secretary may by regulations prescribe,
that it is applying for recognition of its status under this
paragraph,
``(ii) except as provided in section 1322(c)(4) of the
Patient Protection and Affordable Care Act, no part of the
net earnings of which inures to the benefit of any private
shareholder or individual,
``(iii) no substantial part of the activities of which is
carrying on propaganda, or otherwise attempting, to influence
legislation, and
``(iv) the organization does not participate in, or
intervene in (including the publishing or distributing of
statements), any political campaign on behalf of (or in
opposition to) any candidate for public office.''.
(2) Additional reporting requirement.--Section 6033 of such
Code (relating to returns by exempt organizations) is amended
by redesignating subsection (m) as subsection (n) and by
inserting after subsection (l) the following:
``(m) Additional Information Required From CO-OP
Insurers.--An organization described in section 501(c)(29)
shall include on the return required under subsection (a) the
following information:
``(1) The amount of the reserves required by each State in
which the organization is licensed to issue qualified health
plans.
``(2) The amount of reserves on hand.''.
(3) Application of tax on excess benefit transactions.--
Section 4958(e)(1) of such Code (defining applicable tax-
exempt organization) is amended by striking ``paragraph (3)
or (4)'' and inserting ``paragraph (3), (4), or (29)''.
(i) GAO Study and Report.--
(1) Study.--The Comptroller General of the General
Accountability Office shall conduct an ongoing study on
competition and market concentration in the health insurance
market in the United States after the implementation of the
reforms in such market under the provisions of, and the
amendments made by, this Act. Such study shall include an
analysis of new issuers of health insurance in such market.
(2) Report.--The Comptroller General shall, not later than
December 31 of each even-numbered year (beginning with 2014),
report to the appropriate committees of the Congress the
results of the study conducted under paragraph (1), including
any recommendations for administrative or legislative changes
the Comptroller General determines necessary or appropriate
to increase competition in the health insurance market.
SEC. 1323. COMMUNITY HEALTH INSURANCE OPTION.
(a) Voluntary Nature.--
(1) No requirement for health care providers to
participate.--Nothing in this section shall be construed to
require a health care provider to participate in a community
health insurance option, or to impose any penalty for non-
participation.
(2) No requirement for individuals to join.--Nothing in
this section shall be construed to require an individual to
participate in a community health insurance option, or to
impose any penalty for non-participation.
(3) State opt out.--
(A) In general.--A State may elect to prohibit Exchanges in
such State from offering a community health insurance option
if such State enacts a law to provide for such prohibition.
(B) Termination of opt out.--A State may repeal a law
described in subparagraph (A) and provide for the offering of
such an option through the Exchange.
(b) Establishment of Community Health Insurance Option.--
(1) Establishment.--The Secretary shall establish a
community health insurance option to offer, through the
Exchanges established under this title (other than Exchanges
in States that elect to opt out as provided for in subsection
(a)(3)), health care coverage that provides value, choice,
competition, and stability of affordable, high quality
coverage throughout the United States.
(2) Community health insurance option.--In this section,
the term ``community health insurance option'' means health
insurance coverage that--
(A) except as specifically provided for in this section,
complies with the requirements for being a qualified health
plan;
(B) provides high value for the premium charged;
(C) reduces administrative costs and promotes
administrative simplification for beneficiaries;
(D) promotes high quality clinical care;
(E) provides high quality customer service to
beneficiaries;
(F) offers a sufficient choice of providers; and
(G) complies with State laws (if any), except as otherwise
provided for in this title, relating to the laws described in
section 1324(b).
[[Page H1941]]
(3) Essential health benefits.--
(A) General rule.--Except as provided in subparagraph (B),
a community health insurance option offered under this
section shall provide coverage only for the essential health
benefits described in section 1302(b).
(B) States may offer additional benefits.--Nothing in this
section shall preclude a State from requiring that benefits
in addition to the essential health benefits required under
subparagraph (A) be provided to enrollees of a community
health insurance option offered in such State.
(C) Credits.--
(i) In general.--An individual enrolled in a community
health insurance option under this section shall be eligible
for credits under section 36B of the Internal Revenue Code of
1986 in the same manner as an individual who is enrolled in a
qualified health plan.
(ii) No additional federal cost.--A requirement by a State
under subparagraph (B) that benefits in addition to the
essential health benefits required under subparagraph (A) be
provided to enrollees of a community health insurance option
shall not affect the amount of a premium tax credit provided
under section 36B of the Internal Revenue Code of 1986 with
respect to such plan.
(D) State must assume cost.--A State shall make payments to
or on behalf of an eligible individual to defray the cost of
any additional benefits described in subparagraph (B).
(E) Ensuring access to all services.--Nothing in this Act
shall prohibit an individual enrolled in a community health
insurance option from paying out-of-pocket the full cost of
any item or service not included as an essential health
benefit or otherwise covered as a benefit by a health plan.
Nothing in subparagraph (B) shall prohibit any type of
medical provider from accepting an out-of-pocket payment from
an individual enrolled in a community health insurance option
for a service otherwise not included as an essential health
benefit.
(F) Protecting access to end of life care.--A community
health insurance option offered under this section shall be
prohibited from limiting access to end of life care.
(4) Cost sharing.--A community health insurance option
shall offer coverage at each of the levels of coverage
described in section 1302(d).
(5) Premiums.--
(A) Premiums sufficient to cover costs.--The Secretary
shall establish geographically adjusted premium rates in an
amount sufficient to cover expected costs (including claims
and administrative costs) using methods in general use by
qualified health plans.
(B) Applicable rules.--The provisions of title XXVII of the
Public Health Service Act relating to premiums shall apply to
community health insurance options under this section,
including modified community rating provisions under section
2701 of such Act.
(C) Collection of data.--The Secretary shall collect data
as necessary to set premium rates under subparagraph (A).
(D) National pooling.--Notwithstanding any other provision
of law, the Secretary may treat all enrollees in community
health insurance options as members of a single pool.
(E) Contingency margin.--In establishing premium rates
under subparagraph (A), the Secretary shall include an
appropriate amount for a contingency margin.
(6) Reimbursement rates.--
(A) Negotiated rates.--The Secretary shall negotiate rates
for the reimbursement of health care providers for benefits
covered under a community health insurance option.
(B) Limitation.--The rates described in subparagraph (A)
shall not be higher, in aggregate, than the average
reimbursement rates paid by health insurance issuers offering
qualified health plans through the Exchange.
(C) Innovation.--Subject to the limits contained in
subparagraph (A), a State Advisory Council established or
designated under subsection (d) may develop or encourage the
use of innovative payment policies that promote quality,
efficiency and savings to consumers.
(7) Solvency and consumer protection.--
(A) Solvency.--The Secretary shall establish a Federal
solvency standard to be applied with respect to a community
health insurance option. A community health insurance option
shall also be subject to the solvency standard of each State
in which such community health insurance option is offered.
(B) Minimum required.--In establishing the standard
described under subparagraph (A), the Secretary shall require
a reserve fund that shall be equal to at least the dollar
value of the incurred but not reported claims of a community
health insurance option.
(C) Consumer protections.--The consumer protection laws of
a State shall apply to a community health insurance option.
(8) Requirements established in partnership with insurance
commissioners.--
(A) In general.--The Secretary, in collaboration with the
National Association of Insurance Commissioners (in this
paragraph referred to as the ``NAIC''), may promulgate
regulations to establish additional requirements for a
community health insurance option.
(B) Applicability.--Any requirement promulgated under
subparagraph (A) shall be applicable to such option beginning
90 days after the date on which the regulation involved
becomes final.
(c) Start-up Fund.--
(1) Establishment of fund.--
(A) In general.--There is established in the Treasury of
the United States a trust fund to be known as the ``Health
Benefit Plan Start-Up Fund'' (referred to in this section as
the ``Start-Up Fund''), that shall consist of such amounts as
may be appropriated or credited to the Start-Up Fund as
provided for in this subsection to provide loans for the
initial operations of a community health insurance option.
Such amounts shall remain available until expended.
(B) Funding.--There is hereby appropriated to the Start-Up
Fund, out of any moneys in the Treasury not otherwise
appropriated an amount requested by the Secretary of Health
and Human Services as necessary to--
(i) pay the start-up costs associated with the initial
operations of a community health insurance option; and
(ii) pay the costs of making payments on claims submitted
during the period that is not more than 90 days from the date
on which such option is offered.
(2) Use of start-up fund.--The Secretary shall use amounts
contained in the Start-Up Fund to make payments (subject to
the repayment requirements in paragraph (4)) for the purposes
described in paragraph (1)(B).
(3) Pass through of rebates.--The Secretary may establish
procedures for reducing the amount of payments to a
contracting administrator to take into account any rebates or
price concessions.
(4) Repayment.--
(A) In general.--A community health insurance option shall
be required to repay the Secretary of the Treasury (on such
terms as the Secretary may require) for any payments made
under paragraph (1)(B) by the date that is not later than 9
years after the date on which the payment is made. The
Secretary may require the payment of interest with respect to
such repayments at rates that do not exceed the market
interest rate (as determined by the Secretary).
(B) Sanctions in case of for-profit conversion.--In any
case in which the Secretary enters into a contract with a
qualified entity for the offering of a community health
insurance option and such entity is determined to be a for-
profit entity by the Secretary, such entity shall be--
(i) immediately liable to the Secretary for any payments
received by such entity from the Start-Up Fund; and
(ii) permanently ineligible to offer a qualified health
plan.
(d) State Advisory Council.--
(1) Establishment.--A State (other than a State that elects
to opt out as provided for in subsection (a)(3)) shall
establish or designate a public or non-profit private entity
to serve as the State Advisory Council to provide
recommendations to the Secretary on the operations and
policies of a community health insurance option in the State.
Such Council shall provide recommendations on at least the
following:
(A) policies and procedures to integrate quality
improvement and cost containment mechanisms into the health
care delivery system;
(B) mechanisms to facilitate public awareness of the
availability of a community health insurance option; and
(C) alternative payment structures under a community health
insurance option for health care providers that encourage
quality improvement and cost control.
(2) Members.--The members of the State Advisory Council
shall be representatives of the public and shall include
health care consumers and providers.
(3) Applicability of recommendations.--The Secretary may
apply the recommendations of a State Advisory Council to a
community health insurance option in that State, in any other
State, or in all States.
(e) Authority To Contract; Terms of Contract.--
(1) Authority.--
(A) In general.--The Secretary may enter into a contract or
contracts with one or more qualified entities for the purpose
of performing administrative functions (including functions
described in subsection (a)(4) of section 1874A of the Social
Security Act) with respect to a community health insurance
option in the same manner as the Secretary may enter into
contracts under subsection (a)(1) of such section. The
Secretary shall have the same authority with respect to a
community health insurance option under this section as the
Secretary has under subsections (a)(1) and (b) of section
1874A of the Social Security Act with respect to title XVIII
of such Act.
(B) Requirements apply.--If the Secretary enters into a
contract with a qualified entity to offer a community health
insurance option, under such contract such entity--
(i) shall meet the criteria established under paragraph
(2); and
(ii) shall receive an administrative fee under paragraph
(7).
(C) Limitation.--Contracts under this subsection shall not
involve the transfer of insurance risk to the contracting
administrator.
(D) Reference.--An entity with which the Secretary has
entered into a contract under this paragraph shall be
referred to as a ``contracting administrator''.
(2) Qualified entity.--To be qualified to be selected by
the Secretary to offer a community health insurance option,
an entity shall--
(A) meet the criteria established under section 1874A(a)(2)
of the Social Security Act;
(B) be a nonprofit entity for purposes of offering such
option;
(C) meet the solvency standards applicable under subsection
(b)(7);
(D) be eligible to offer health insurance or health
benefits coverage;
(E) meet quality standards specified by the Secretary;
(F) have in place effective procedures to control fraud,
abuse, and waste; and
(G) meet such other requirements as the Secretary may
impose.
Procedures described under subparagraph (F) shall include the
implementation of procedures to use beneficiary identifiers
to identify individuals entitled to benefits so that such an
individual's social security account number is not used,
[[Page H1942]]
and shall also include procedures for the use of technology
(including front-end, prepayment intelligent data-matching
technology similar to that used by hedge funds, investment
funds, and banks) to provide real-time data analysis of
claims for payment under this title to identify and
investigate unusual billing or order practices under this
title that could indicate fraud or abuse.
(3) Term.--A contract provided for under paragraph (1)
shall be for a term of at least 5 years but not more than 10
years, as determined by the Secretary. At the end of each
such term, the Secretary shall conduct a competitive bidding
process for the purposes of renewing existing contracts or
selecting new qualified entities with which to enter into
contracts under such paragraph.
(4) Limitation.--A contract may not be renewed under this
subsection unless the Secretary determines that the
contracting administrator has met performance requirements
established by the Secretary in the areas described in
paragraph (7)(B).
(5) Audits.--The Inspector General shall conduct periodic
audits with respect to contracting administrators under this
subsection to ensure that the administrator involved is in
compliance with this section.
(6) Revocation.--A contract awarded under this subsection
shall be revoked by the Secretary, upon the recommendation of
the Inspector General, only after notice to the contracting
administrator involved and an opportunity for a hearing. The
Secretary may revoke such contract if the Secretary
determines that such administrator has engaged in fraud,
deception, waste, abuse of power, negligence, mismanagement
of taxpayer dollars, or gross mismanagement. An entity that
has had a contract revoked under this paragraph shall not be
qualified to enter into a subsequent contract under this
subsection.
(7) Fee for administration.--
(A) In general.--The Secretary shall pay the contracting
administrator a fee for the management, administration, and
delivery of the benefits under this section.
(B) Requirement for high quality administration.--The
Secretary may increase the fee described in subparagraph (A)
by not more than 10 percent, or reduce the fee described in
subparagraph (A) by not more than 50 percent, based on the
extent to which the contracting administrator, in the
determination of the Secretary, meets performance
requirements established by the Secretary, in at least the
following areas:
(i) Maintaining low premium costs and low cost sharing
requirements, provided that such requirements are consistent
with section 1302.
(ii) Reducing administrative costs and promoting
administrative simplification for beneficiaries.
(iii) Promoting high quality clinical care.
(iv) Providing high quality customer service to
beneficiaries.
(C) Non-renewal.--The Secretary may not renew a contract to
offer a community health insurance option under this section
with any contracting entity that has been assessed more than
one reduction under subparagraph (B) during the contract
period.
(8) Limitation.--Notwithstanding the terms of a contract
under this subsection, the Secretary shall negotiate the
reimbursement rates for purposes of subsection (b)(6).
(f) Report by HHS and Insolvency Warnings.--
(1) In general.--On an annual basis, the Secretary shall
conduct a study on the solvency of a community health
insurance option and submit to Congress a report describing
the results of such study.
(2) Result.--If, in any year, the result of the study under
paragraph (1) is that a community health insurance option is
insolvent, such result shall be treated as a community health
insurance option solvency warning.
(3) Submission of plan and procedure.--
(A) In general.--If there is a community health insurance
option solvency warning under paragraph (2) made in a year,
the President shall submit to Congress, within the 15-day
period beginning on the date of the budget submission to
Congress under section 1105(a) of title 31, United States
Code, for the succeeding year, proposed legislation to
respond to such warning.
(B) Procedure.--In the case of a legislative proposal
submitted by the President pursuant to subparagraph (A), such
proposal shall be considered by Congress using the same
procedures described under sections 803 and 804 of the
Medicare Prescription Drug, Improvement, and Modernization
Act of 2003 that shall be used for a medicare funding
warning.
(g) Marketing Parity.--In a facility controlled by the
Federal Government, or by a State, where marketing or
promotional materials related to a community health insurance
option are made available to the public, making available
marketing or promotional materials relating to private health
insurance plans shall not be prohibited. Such materials
include informational pamphlets, guidebooks, enrollment
forms, or other materials determined reasonable for display.
(h) Authorization of Appropriations.--There is authorized
to be appropriated such sums as may be necessary to carry out
this section.
SEC. 1324. LEVEL PLAYING FIELD.
(a) In General.--Notwithstanding any other provision of
law, any health insurance coverage offered by a private
health insurance issuer shall not be subject to any Federal
or State law described in subsection (b) if a qualified
health plan offered under the Consumer Operated and Oriented
Plan program under section 1322, a community health insurance
option under section 1323, or a nationwide qualified health
plan under section 1333(b), is not subject to such law.
(b) Laws Described.--The Federal and State laws described
in this subsection are those Federal and State laws relating
to--
(1) guaranteed renewal;
(2) rating;
(3) preexisting conditions;
(4) non-discrimination;
(5) quality improvement and reporting;
(6) fraud and abuse;
(7) solvency and financial requirements;
(8) market conduct;
(9) prompt payment;
(10) appeals and grievances;
(11) privacy and confidentiality;
(12) licensure; and
(13) benefit plan material or information.
PART IV--STATE FLEXIBILITY TO ESTABLISH ALTERNATIVE PROGRAMS
SEC. 1331. STATE FLEXIBILITY TO ESTABLISH BASIC HEALTH
PROGRAMS FOR LOW-INCOME INDIVIDUALS NOT
ELIGIBLE FOR MEDICAID.
(a) Establishment of Program.--
(1) In general.--The Secretary shall establish a basic
health program meeting the requirements of this section under
which a State may enter into contracts to offer 1 or more
standard health plans providing at least the essential health
benefits described in section 1302(b) to eligible individuals
in lieu of offering such individuals coverage through an
Exchange.
(2) Certifications as to benefit coverage and costs.--Such
program shall provide that a State may not establish a basic
health program under this section unless the State
establishes to the satisfaction of the Secretary, and the
Secretary certifies, that--
(A) in the case of an eligible individual enrolled in a
standard health plan offered through the program, the State
provides--
(i) that the amount of the monthly premium an eligible
individual is required to pay for coverage under the standard
health plan for the individual and the individual's
dependents does not exceed the amount of the monthly premium
that the eligible individual would have been required to pay
(in the rating area in which the individual resides) if the
individual had enrolled in the applicable second lowest cost
silver plan (as defined in section 36B(b)(3)(B) of the
Internal Revenue Code of 1986) offered to the individual
through an Exchange; and
(ii) that the cost-sharing an eligible individual is
required to pay under the standard health plan does not
exceed--
(I) the cost-sharing required under a platinum plan in the
case of an eligible individual with household income not in
excess of 150 percent of the poverty line for the size of the
family involved; and
(II) the cost-sharing required under a gold plan in the
case of an eligible individual not described in subclause
(I); and
(B) the benefits provided under the standard health plans
offered through the program cover at least the essential
health benefits described in section 1302(b).
For purposes of subparagraph (A)(i), the amount of the
monthly premium an individual is required to pay under either
the standard health plan or the applicable second lowest cost
silver plan shall be determined after reduction for any
premium tax credits and cost-sharing reductions allowable
with respect to either plan.
(b) Standard Health Plan.--In this section, the term
``standard heath plan'' means a health benefits plan that the
State contracts with under this section--
(1) under which the only individuals eligible to enroll are
eligible individuals;
(2) that provides at least the essential health benefits
described in section 1302(b); and
(3) in the case of a plan that provides health insurance
coverage offered by a health insurance issuer, that has a
medical loss ratio of at least 85 percent.
(c) Contracting Process.--
(1) In general.--A State basic health program shall
establish a competitive process for entering into contracts
with standard health plans under subsection (a), including
negotiation of premiums and cost-sharing and negotiation of
benefits in addition to the essential health benefits
described in section 1302(b).
(2) Specific items to be considered.--A State shall, as
part of its competitive process under paragraph (1), include
at least the following:
(A) Innovation.--Negotiation with offerors of a standard
health plan for the inclusion of innovative features in the
plan, including--
(i) care coordination and care management for enrollees,
especially for those with chronic health conditions;
(ii) incentives for use of preventive services; and
(iii) the establishment of relationships between providers
and patients that maximize patient involvement in health care
decision-making, including providing incentives for
appropriate utilization under the plan.
(B) Health and resource differences.--Consideration of, and
the making of suitable allowances for, differences in health
care needs of enrollees and differences in local availability
of, and access to, health care providers. Nothing in this
subparagraph shall be construed as allowing discrimination on
the basis of pre-existing conditions or other health status-
related factors.
(C) Managed care.--Contracting with managed care systems,
or with systems that offer as many of the attributes of
managed care as are feasible in the local health care market.
(D) Performance measures.--Establishing specific
performance measures and standards for issuers of standard
health plans that focus on quality of care and improved
health outcomes, requiring such plans to report to the State
with respect to the measures and standards, and making the
performance and quality information available to enrollees in
a useful form.
[[Page H1943]]
(3) Enhanced availability.--
(A) Multiple plans.--A State shall, to the maximum extent
feasible, seek to make multiple standard health plans
available to eligible individuals within a State to ensure
individuals have a choice of such plans.
(B) Regional compacts.--A State may negotiate a regional
compact with other States to include coverage of eligible
individuals in all such States in agreements with issuers of
standard health plans.
(4) Coordination with other state programs.--A State shall
seek to coordinate the administration of, and provision of
benefits under, its program under this section with the State
medicaid program under title XIX of the Social Security Act,
the State child health plan under title XXI of such Act, and
other State-administered health programs to maximize the
efficiency of such programs and to improve the continuity of
care.
(d) Transfer of Funds to States.--
(1) In general.--If the Secretary determines that a State
electing the application of this section meets the
requirements of the program established under subsection (a),
the Secretary shall transfer to the State for each fiscal
year for which 1 or more standard health plans are operating
within the State the amount determined under paragraph (3).
(2) Use of funds.--A State shall establish a trust for the
deposit of the amounts received under paragraph (1) and
amounts in the trust fund shall only be used to reduce the
premiums and cost-sharing of, or to provide additional
benefits for, eligible individuals enrolled in standard
health plans within the State. Amounts in the trust fund, and
expenditures of such amounts, shall not be included in
determining the amount of any non-Federal funds for purposes
of meeting any matching or expenditure requirement of any
federally-funded program.
(3) Amount of payment.--
(A) Secretarial determination.--
(i) In general.--The amount determined under this paragraph
for any fiscal year is the amount the Secretary determines is
equal to 85 percent of the premium tax credits under section
36B of the Internal Revenue Code of 1986, and the cost-
sharing reductions under section 1402, that would have been
provided for the fiscal year to eligible individuals enrolled
in standard health plans in the State if such eligible
individuals were allowed to enroll in qualified health plans
through an Exchange established under this subtitle.
(ii) Specific requirements.--The Secretary shall make the
determination under clause (i) on a per enrollee basis and
shall take into account all relevant factors necessary to
determine the value of the premium tax credits and cost-
sharing reductions that would have been provided to eligible
individuals described in clause (i), including the age and
income of the enrollee, whether the enrollment is for self-
only or family coverage, geographic differences in average
spending for health care across rating areas, the health
status of the enrollee for purposes of determining risk
adjustment payments and reinsurance payments that would have
been made if the enrollee had enrolled in a qualified health
plan through an Exchange, and whether any reconciliation of
the credit or cost-sharing reductions would have occurred if
the enrollee had been so enrolled. This determination shall
take into consideration the experience of other States with
respect to participation in an Exchange and such credits and
reductions provided to residents of the other States, with a
special focus on enrollees with income below 200 percent of
poverty.
(iii) Certification.--The Chief Actuary of the Centers for
Medicare & Medicaid Services, in consultation with the Office
of Tax Analysis of the Department of the Treasury, shall
certify whether the methodology used to make determinations
under this subparagraph, and such determinations, meet the
requirements of clause (ii). Such certifications shall be
based on sufficient data from the State and from comparable
States about their experience with programs created by this
Act.
(B) Corrections.--The Secretary shall adjust the payment
for any fiscal year to reflect any error in the
determinations under subparagraph (A) for any preceding
fiscal year.
(4) Application of special rules.--The provisions of
section 1303 shall apply to a State basic health program, and
to standard health plans offered through such program, in the
same manner as such rules apply to qualified health plans.
(e) Eligible Individual.--
(1) In general.--In this section, the term ``eligible
individual'' means, with respect to any State, an
individual--
(A) who a resident of the State who is not eligible to
enroll in the State's medicaid program under title XIX of the
Social Security Act for benefits that at a minimum consist of
the essential health benefits described in section 1302(b);
(B) whose household income exceeds 133 percent but does not
exceed 200 percent of the poverty line for the size of the
family involved;
(C) who is not eligible for minimum essential coverage (as
defined in section 5000A(f) of the Internal Revenue Code of
1986) or is eligible for an employer-sponsored plan that is
not affordable coverage (as determined under section
5000A(e)(2) of such Code); and
(D) who has not attained age 65 as of the beginning of the
plan year.
Such term shall not include any individual who is not a
qualified individual under section 1312 who is eligible to be
covered by a qualified health plan offered through an
Exchange.
(2) Eligible individuals may not use exchange.--An eligible
individual shall not be treated as a qualified individual
under section 1312 eligible for enrollment in a qualified
health plan offered through an Exchange established under
section 1311.
(f) Secretarial Oversight.--The Secretary shall each year
conduct a review of each State program to ensure compliance
with the requirements of this section, including ensuring
that the State program meets--
(1) eligibility verification requirements for participation
in the program;
(2) the requirements for use of Federal funds received by
the program; and
(3) the quality and performance standards under this
section.
(g) Standard Health Plan Offerors.--A State may provide
that persons eligible to offer standard health plans under a
basic health program established under this section may
include a licensed health maintenance organization, a
licensed health insurance insurer, or a network of health
care providers established to offer services under the
program.
(h) Definitions.--Any term used in this section which is
also used in section 36B of the Internal Revenue Code of 1986
shall have the meaning given such term by such section.
SEC. 1332. WAIVER FOR STATE INNOVATION.
(a) Application.--
(1) In general.--A State may apply to the Secretary for the
waiver of all or any requirements described in paragraph (2)
with respect to health insurance coverage within that State
for plan years beginning on or after January 1, 2017. Such
application shall--
(A) be filed at such time and in such manner as the
Secretary may require;
(B) contain such information as the Secretary may require,
including--
(i) a comprehensive description of the State legislation
and program to implement a plan meeting the requirements for
a waiver under this section; and
(ii) a 10-year budget plan for such plan that is budget
neutral for the Federal Government; and
(C) provide an assurance that the State has enacted the law
described in subsection (b)(2).
(2) Requirements.--The requirements described in this
paragraph with respect to health insurance coverage within
the State for plan years beginning on or after January 1,
2014, are as follows:
(A) Part I of subtitle D.
(B) Part II of subtitle D.
(C) Section 1402.
(D) Sections 36B, 4980H, and 5000A of the Internal Revenue
Code of 1986.
(3) Pass through of funding.--With respect to a State
waiver under paragraph (1), under which, due to the structure
of the State plan, individuals and small employers in the
State would not qualify for the premium tax credits, cost-
sharing reductions, or small business credits under sections
36B of the Internal Revenue Code of 1986 or under part I of
subtitle E for which they would otherwise be eligible, the
Secretary shall provide for an alternative means by which the
aggregate amount of such credits or reductions that would
have been paid on behalf of participants in the Exchanges
established under this title had the State not received such
waiver, shall be paid to the State for purposes of
implementing the State plan under the waiver. Such amount
shall be determined annually by the Secretary, taking into
consideration the experience of other States with respect to
participation in an Exchange and credits and reductions
provided under such provisions to residents of the other
States.
(4) Waiver consideration and transparency.--
(A) In general.--An application for a waiver under this
section shall be considered by the Secretary in accordance
with the regulations described in subparagraph (B).
(B) Regulations.--Not later than 180 days after the date of
enactment of this Act, the Secretary shall promulgate
regulations relating to waivers under this section that
provide--
(i) a process for public notice and comment at the State
level, including public hearings, sufficient to ensure a
meaningful level of public input;
(ii) a process for the submission of an application that
ensures the disclosure of--
(I) the provisions of law that the State involved seeks to
waive; and
(II) the specific plans of the State to ensure that the
waiver will be in compliance with subsection (b);
(iii) a process for providing public notice and comment
after the application is received by the Secretary, that is
sufficient to ensure a meaningful level of public input and
that does not impose requirements that are in addition to, or
duplicative of, requirements imposed under the Administrative
Procedures Act, or requirements that are unreasonable or
unnecessarily burdensome with respect to State compliance;
(iv) a process for the submission to the Secretary of
periodic reports by the State concerning the implementation
of the program under the waiver; and
(v) a process for the periodic evaluation by the Secretary
of the program under the waiver.
(C) Report.--The Secretary shall annually report to
Congress concerning actions taken by the Secretary with
respect to applications for waivers under this section.
(5) Coordinated waiver process.--The Secretary shall
develop a process for coordinating and consolidating the
State waiver processes applicable under the provisions of
this section, and the existing waiver processes applicable
under titles XVIII, XIX, and XXI of the Social Security Act,
and any other Federal law relating to the provision of health
care items or services. Such process shall permit a State to
submit a single application for a waiver under any or all of
such provisions.
(6) Definition.--In this section, the term ``Secretary''
means--
[[Page H1944]]
(A) the Secretary of Health and Human Services with respect
to waivers relating to the provisions described in
subparagraph (A) through (C) of paragraph (2); and
(B) the Secretary of the Treasury with respect to waivers
relating to the provisions described in paragraph (2)(D).
(b) Granting of Waivers.--
(1) In general.--The Secretary may grant a request for a
waiver under subsection (a)(1) only if the Secretary
determines that the State plan--
(A) will provide coverage that is at least as comprehensive
as the coverage defined in section 1302(b) and offered
through Exchanges established under this title as certified
by Office of the Actuary of the Centers for Medicare &
Medicaid Services based on sufficient data from the State and
from comparable States about their experience with programs
created by this Act and the provisions of this Act that would
be waived;
(B) will provide coverage and cost sharing protections
against excessive out-of-pocket spending that are at least as
affordable as the provisions of this title would provide;
(C) will provide coverage to at least a comparable number
of its residents as the provisions of this title would
provide; and
(D) will not increase the Federal deficit.
(2) Requirement to enact a law.--
(A) In general.--A law described in this paragraph is a
State law that provides for State actions under a waiver
under this section, including the implementation of the State
plan under subsection (a)(1)(B).
(B) Termination of opt out.--A State may repeal a law
described in subparagraph (A) and terminate the authority
provided under the waiver with respect to the State.
(c) Scope of Waiver.--
(1) In general.--The Secretary shall determine the scope of
a waiver of a requirement described in subsection (a)(2)
granted to a State under subsection (a)(1).
(2) Limitation.--The Secretary may not waive under this
section any Federal law or requirement that is not within the
authority of the Secretary.
(d) Determinations by Secretary.--
(1) Time for determination.--The Secretary shall make a
determination under subsection (a)(1) not later than 180 days
after the receipt of an application from a State under such
subsection.
(2) Effect of determination.--
(A) Granting of waivers.--If the Secretary determines to
grant a waiver under subsection (a)(1), the Secretary shall
notify the State involved of such determination and the terms
and effectiveness of such waiver.
(B) Denial of waiver.--If the Secretary determines a waiver
should not be granted under subsection (a)(1), the Secretary
shall notify the State involved, and the appropriate
committees of Congress of such determination and the reasons
therefore.
(e) Term of Waiver.--No waiver under this section may
extend over a period of longer than 5 years unless the State
requests continuation of such waiver, and such request shall
be deemed granted unless the Secretary, within 90 days after
the date of its submission to the Secretary, either denies
such request in writing or informs the State in writing with
respect to any additional information which is needed in
order to make a final determination with respect to the
request.
SEC. 1333. PROVISIONS RELATING TO OFFERING OF PLANS IN MORE
THAN ONE STATE.
(a) Health Care Choice Compacts.--
(1) In general.--Not later than July 1, 2013, the Secretary
shall, in consultation with the National Association of
Insurance Commissioners, issue regulations for the creation
of health care choice compacts under which 2 or more States
may enter into an agreement under which--
(A) 1 or more qualified health plans could be offered in
the individual markets in all such States but, except as
provided in subparagraph (B), only be subject to the laws and
regulations of the State in which the plan was written or
issued;
(B) the issuer of any qualified health plan to which the
compact applies--
(i) would continue to be subject to market conduct, unfair
trade practices, network adequacy, and consumer protection
standards (including standards relating to rating), including
addressing disputes as to the performance of the contract, of
the State in which the purchaser resides;
(ii) would be required to be licensed in each State in
which it offers the plan under the compact or to submit to
the jurisdiction of each such State with regard to the
standards described in clause (i) (including allowing access
to records as if the insurer were licensed in the State); and
(iii) must clearly notify consumers that the policy may not
be subject to all the laws and regulations of the State in
which the purchaser resides.
(2) State authority.--A State may not enter into an
agreement under this subsection unless the State enacts a law
after the date of the enactment of this title that
specifically authorizes the State to enter into such
agreements.
(3) Approval of compacts.--The Secretary may approve
interstate health care choice compacts under paragraph (1)
only if the Secretary determines that such health care choice
compact--
(A) will provide coverage that is at least as comprehensive
as the coverage defined in section 1302(b) and offered
through Exchanges established under this title;
(B) will provide coverage and cost sharing protections
against excessive out-of-pocket spending that are at least as
affordable as the provisions of this title would provide;
(C) will provide coverage to at least a comparable number
of its residents as the provisions of this title would
provide;
(D) will not increase the Federal deficit; and
(E) will not weaken enforcement of laws and regulations
described in paragraph (1)(B)(i) in any State that is
included in such compact.
(4) Effective date.--A health care choice compact described
in paragraph (1) shall not take effect before January 1,
2016.
(b) Authority for Nationwide Plans.--
(1) In general.--Except as provided in paragraph (2), if an
issuer (including a group of health insurance issuers
affiliated either by common ownership and control or by the
common use of a nationally licensed service mark) of a
qualified health plan in the individual or small group market
meets the requirements of this subsection (in this subsection
a ``nationwide qualified health plan'')--
(A) the issuer of the plan may offer the nationwide
qualified health plan in the individual or small group market
in more than 1 State; and
(B) with respect to State laws mandating benefit coverage
by a health plan, only the State laws of the State in which
such plan is written or issued shall apply to the nationwide
qualified health plan.
(2) State opt-out.--A State may, by specific reference in a
law enacted after the date of enactment of this title,
provide that this subsection shall not apply to that State.
Such opt-out shall be effective until such time as the State
by law revokes it.
(3) Plan requirements.--An issuer meets the requirements of
this subsection with respect to a nationwide qualified health
plan if, in the determination of the Secretary--
(A) the plan offers a benefits package that is uniform in
each State in which the plan is offered and meets the
requirements set forth in paragraphs (4) through (6);
(B) the issuer is licensed in each State in which it offers
the plan and is subject to all requirements of State law not
inconsistent with this section, including but not limited to,
the standards and requirements that a State imposes that do
not prevent the application of a requirement of part A of
title XXVII of the Public Health Service Act or a requirement
of this title;
(C) the issuer meets all requirements of this title with
respect to a qualified health plan, including the requirement
to offer the silver and gold levels of the plan in each
Exchange in the State for the market in which the plan is
offered;
(D) the issuer determines the premiums for the plan in any
State on the basis of the rating rules in effect in that
State for the rating areas in which it is offered;
(E) the issuer offers the nationwide qualified health plan
in at least 60 percent of the participating States in the
first year in which the plan is offered, 65 percent of such
States in the second year, 70 percent of such States in the
third year, 75 percent of such States in the fourth year, and
80 percent of such States in the fifth and subsequent years;
(F) the issuer shall offer the plan in participating States
across the country, in all geographic regions, and in all
States that have adopted adjusted community rating before the
date of enactment of this Act; and
(G) the issuer clearly notifies consumers that the policy
may not contain some benefits otherwise mandated for plans in
the State in which the purchaser resides and provides a
detailed statement of the benefits offered and the benefit
differences in that State, in accordance with rules
promulgated by the Secretary.
(4) Form review for nationwide plans.--Notwithstanding any
contrary provision of State law, at least 3 months before any
nationwide qualified health plan is offered, the issuer shall
file all nationwide qualified health plan forms with the
regulator in each participating State in which the plan will
be offered. An issuer may appeal the disapproval of a
nationwide qualified health plan form to the Secretary.
(5) Applicable rules.--The Secretary shall, in consultation
with the National Association of Insurance Commissioners,
issue rules for the offering of nationwide qualified health
plans under this subsection. Nationwide qualified health
plans may be offered only after such rules have taken effect.
(6) Coverage.--The Secretary shall provide that the health
benefits coverage provided to an individual through a
nationwide qualified health plan under this subsection shall
include at least the essential benefits package described in
section 1302.
(7) State law mandating benefit coverage by a health
benefits plan.--For the purposes of this subsection, a State
law mandating benefit coverage by a health plan is a law that
mandates health insurance coverage or the offer of health
insurance coverage for specific health services or specific
diseases. A law that mandates health insurance coverage or
reimbursement for services provided by certain classes of
providers of health care services, or a law that mandates
that certain classes of individuals must be covered as a
group or as dependents, is not a State law mandating benefit
coverage by a health benefits plan.
PART V--REINSURANCE AND RISK ADJUSTMENT
SEC. 1341. TRANSITIONAL REINSURANCE PROGRAM FOR INDIVIDUAL
AND SMALL GROUP MARKETS IN EACH STATE.
(a) In General.--Each State shall, not later than January
1, 2014--
(1) include in the Federal standards or State law or
regulation the State adopts and has in effect under section
1321(b) the provisions described in subsection (b); and
(2) establish (or enter into a contract with) 1 or more
applicable reinsurance entities to carry out the reinsurance
program under this section.
(b) Model Regulation.--
(1) In general.--In establishing the Federal standards
under section 1321(a), the Secretary,
[[Page H1945]]
in consultation with the National Association of Insurance
Commissioners (the ``NAIC''), shall include provisions that
enable States to establish and maintain a program under
which--
(A) health insurance issuers, and third party
administrators on behalf of group health plans, are required
to make payments to an applicable reinsurance entity for any
plan year beginning in the 3-year period beginning January 1,
2014 (as specified in paragraph (3); and
(B) the applicable reinsurance entity collects payments
under subparagraph (A) and uses amounts so collected to make
reinsurance payments to health insurance issuers described in
subparagraph (A) that cover high risk individuals in the
individual market (excluding grandfathered health plans) for
any plan year beginning in such 3-year period.
(2) High-risk individual; payment amounts.--The Secretary
shall include the following in the provisions under paragraph
(1):
(A) Determination of high-risk individuals.--The method by
which individuals will be identified as high risk individuals
for purposes of the reinsurance program established under
this section. Such method shall provide for identification of
individuals as high-risk individuals on the basis of--
(i) a list of at least 50 but not more than 100 medical
conditions that are identified as high-risk conditions and
that may be based on the identification of diagnostic and
procedure codes that are indicative of individuals with pre-
existing, high-risk conditions; or
(ii) any other comparable objective method of
identification recommended by the American Academy of
Actuaries.
(B) Payment amount.--The formula for determining the amount
of payments that will be paid to health insurance issuers
described in paragraph (1)(A) that insure high-risk
individuals. Such formula shall provide for the equitable
allocation of available funds through reconciliation and may
be designed--
(i) to provide a schedule of payments that specifies the
amount that will be paid for each of the conditions
identified under subparagraph (A); or
(ii) to use any other comparable method for determining
payment amounts that is recommended by the American Academy
of Actuaries and that encourages the use of care coordination
and care management programs for high risk conditions.
(3) Determination of required contributions.--
(A) In general.--The Secretary shall include in the
provisions under paragraph (1) the method for determining the
amount each health insurance issuer and group health plan
described in paragraph (1)(A) contributing to the reinsurance
program under this section is required to contribute under
such paragraph for each plan year beginning in the 36-month
period beginning January 1, 2014. The contribution amount for
any plan year may be based on the percentage of revenue of
each issuer and the total costs of providing benefits to
enrollees in self-insured plans or on a specified amount per
enrollee and may be required to be paid in advance or
periodically throughout the plan year.
(B) Specific requirements.--The method under this paragraph
shall be designed so that--
(i) the contribution amount for each issuer proportionally
reflects each issuer's fully insured commercial book of
business for all major medical products and the total value
of all fees charged by the issuer and the costs of coverage
administered by the issuer as a third party administrator;
(ii) the contribution amount can include an additional
amount to fund the administrative expenses of the applicable
reinsurance entity;
(iii) the aggregate contribution amounts for all States
shall, based on the best estimates of the NAIC and without
regard to amounts described in clause (ii), equal
$10,000,000,000 for plan years beginning in 2014,
$6,000,000,000 for plan years beginning 2015, and
$4,000,000,000 for plan years beginning in 2016; and
(iv) in addition to the aggregate contribution amounts
under clause (iii), each issuer's contribution amount for any
calendar year under clause (iii) reflects its proportionate
share of an additional $2,000,000,000 for 2014, an additional
$2,000,000,000 for 2015, and an additional $1,000,000,000 for
2016.
Nothing in this subparagraph shall be construed to preclude a
State from collecting additional amounts from issuers on a
voluntary basis.
(4) Expenditure of funds.--The provisions under paragraph
(1) shall provide that--
(A) the contribution amounts collected for any calendar
year may be allocated and used in any of the three calendar
years for which amounts are collected based on the
reinsurance needs of a particular period or to reflect
experience in a prior period; and
(B) amounts remaining unexpended as of December, 2016, may
be used to make payments under any reinsurance program of a
State in the individual market in effect in the 2-year period
beginning on January 1, 2017.
Notwithstanding the preceding sentence, any contribution
amounts described in paragraph (3)(B)(iv) shall be deposited
into the general fund of the Treasury of the United States
and may not be used for the program established under this
section.
(c) Applicable Reinsurance Entity.--For purposes of this
section--
(1) In general.--The term ``applicable reinsurance entity''
means a not-for-profit organization--
(A) the purpose of which is to help stabilize premiums for
coverage in the individual and small group markets in a State
during the first 3 years of operation of an Exchange for such
markets within the State when the risk of adverse selection
related to new rating rules and market changes is greatest;
and
(B) the duties of which shall be to carry out the
reinsurance program under this section by coordinating the
funding and operation of the risk-spreading mechanisms
designed to implement the reinsurance program.
(2) State discretion.--A State may have more than 1
applicable reinsurance entity to carry out the reinsurance
program under this section within the State and 2 or more
States may enter into agreements to provide for an applicable
reinsurance entity to carry out such program in all such
States.
(3) Entities are tax-exempt.--An applicable reinsurance
entity established under this section shall be exempt from
taxation under chapter 1 of the Internal Revenue Code of
1986. The preceding sentence shall not apply to the tax
imposed by section 511 such Code (relating to tax on
unrelated business taxable income of an exempt organization).
(d) Coordination With State High-risk Pools.--The State
shall eliminate or modify any State high-risk pool to the
extent necessary to carry out the reinsurance program
established under this section. The State may coordinate the
State high-risk pool with such program to the extent not
inconsistent with the provisions of this section.
SEC. 1342. ESTABLISHMENT OF RISK CORRIDORS FOR PLANS IN
INDIVIDUAL AND SMALL GROUP MARKETS.
(a) In General.--The Secretary shall establish and
administer a program of risk corridors for calendar years
2014, 2015, and 2016 under which a qualified health plan
offered in the individual or small group market shall
participate in a payment adjustment system based on the ratio
of the allowable costs of the plan to the plan's aggregate
premiums. Such program shall be based on the program for
regional participating provider organizations under part D of
title XVIII of the Social Security Act.
(b) Payment Methodology.--
(1) Payments out.--The Secretary shall provide under the
program established under subsection (a) that if--
(A) a participating plan's allowable costs for any plan
year are more than 103 percent but not more than 108 percent
of the target amount, the Secretary shall pay to the plan an
amount equal to 50 percent of the target amount in excess of
103 percent of the target amount; and
(B) a participating plan's allowable costs for any plan
year are more than 108 percent of the target amount, the
Secretary shall pay to the plan an amount equal to the sum of
2.5 percent of the target amount plus 80 percent of allowable
costs in excess of 108 percent of the target amount.
(2) Payments in.--The Secretary shall provide under the
program established under subsection (a) that if--
(A) a participating plan's allowable costs for any plan
year are less than 97 percent but not less than 92 percent of
the target amount, the plan shall pay to the Secretary an
amount equal to 50 percent of the excess of 97 percent of the
target amount over the allowable costs; and
(B) a participating plan's allowable costs for any plan
year are less than 92 percent of the target amount, the plan
shall pay to the Secretary an amount equal to the sum of 2.5
percent of the target amount plus 80 percent of the excess of
92 percent of the target amount over the allowable costs.
(c) Definitions.--In this section:
(1) Allowable costs.--
(A) In general.--The amount of allowable costs of a plan
for any year is an amount equal to the total costs (other
than administrative costs) of the plan in providing benefits
covered by the plan.
(B) Reduction for risk adjustment and reinsurance
payments.--Allowable costs shall reduced by any risk
adjustment and reinsurance payments received under section
1341 and 1343.
(2) Target amount.--The target amount of a plan for any
year is an amount equal to the total premiums (including any
premium subsidies under any governmental program), reduced by
the administrative costs of the plan.
SEC. 1343. RISK ADJUSTMENT.
(a) In General.--
(1) Low actuarial risk plans.--Using the criteria and
methods developed under subsection (b), each State shall
assess a charge on health plans and health insurance issuers
(with respect to health insurance coverage) described in
subsection (c) if the actuarial risk of the enrollees of such
plans or coverage for a year is less than the average
actuarial risk of all enrollees in all plans or coverage in
such State for such year that are not self-insured group
health plans (which are subject to the provisions of the
Employee Retirement Income Security Act of 1974).
(2) High actuarial risk plans.--Using the criteria and
methods developed under subsection (b), each State shall
provide a payment to health plans and health insurance
issuers (with respect to health insurance coverage) described
in subsection (c) if the actuarial risk of the enrollees of
such plans or coverage for a year is greater than the average
actuarial risk of all enrollees in all plans and coverage in
such State for such year that are not self-insured group
health plans (which are subject to the provisions of the
Employee Retirement Income Security Act of 1974).
(b) Criteria and Methods.--The Secretary, in consultation
with States, shall establish criteria and methods to be used
in carrying out the risk adjustment activities under this
section. The Secretary may utilize criteria and methods
similar to the criteria and methods utilized under part C or
D of title XVIII of the Social Security Act. Such criteria
and methods shall be included in the standards and
requirements the Secretary prescribes under section 1321.
(c) Scope.--A health plan or a health insurance issuer is
described in this subsection if such
[[Page H1946]]
health plan or health insurance issuer provides coverage in
the individual or small group market within the State. This
subsection shall not apply to a grandfathered health plan or
the issuer of a grandfathered health plan with respect to
that plan.
Subtitle E--Affordable Coverage Choices for All Americans
PART I--PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS
Subpart A--Premium Tax Credits and Cost-sharing Reductions
SEC. 1401. REFUNDABLE TAX CREDIT PROVIDING PREMIUM ASSISTANCE
FOR COVERAGE UNDER A QUALIFIED HEALTH PLAN.
(a) In General.--Subpart C of part IV of subchapter A of
chapter 1 of the Internal Revenue Code of 1986 (relating to
refundable credits) is amended by inserting after section 36A
the following new section:
``SEC. 36B. REFUNDABLE CREDIT FOR COVERAGE UNDER A QUALIFIED
HEALTH PLAN.
``(a) In General.--In the case of an applicable taxpayer,
there shall be allowed as a credit against the tax imposed by
this subtitle for any taxable year an amount equal to the
premium assistance credit amount of the taxpayer for the
taxable year.
``(b) Premium Assistance Credit Amount.--For purposes of
this section--
``(1) In general.--The term `premium assistance credit
amount' means, with respect to any taxable year, the sum of
the premium assistance amounts determined under paragraph (2)
with respect to all coverage months of the taxpayer occurring
during the taxable year.
``(2) Premium assistance amount.--The premium assistance
amount determined under this subsection with respect to any
coverage month is the amount equal to the lesser of--
``(A) the monthly premiums for such month for 1 or more
qualified health plans offered in the individual market
within a State which cover the taxpayer, the taxpayer's
spouse, or any dependent (as defined in section 152) of the
taxpayer and which were enrolled in through an Exchange
established by the State under 1311 of the Patient Protection
and Affordable Care Act, or
``(B) the excess (if any) of--
``(i) the adjusted monthly premium for such month for the
applicable second lowest cost silver plan with respect to the
taxpayer, over
``(ii) an amount equal to 1/12 of the product of the
applicable percentage and the taxpayer's household income for
the taxable year.
``(3) Other terms and rules relating to premium assistance
amounts.--For purposes of paragraph (2)--
``(A) Applicable percentage.--
``(i) In general.--Except as provided in clause (ii), the
applicable percentage with respect to any taxpayer for any
taxable year is equal to 2.8 percent, increased by the number
of percentage points (not greater than 7) which bears the
same ratio to 7 percentage points as--
``(I) the taxpayer's household income for the taxable year
in excess of 100 percent of the poverty line for a family of
the size involved, bears to
``(II) an amount equal to 200 percent of the poverty line
for a family of the size involved.
``(ii) Special rule for taxpayers under 133 percent of
poverty line.--If a taxpayer's household income for the
taxable year is in excess of 100 percent, but not more than
133 percent, of the poverty line for a family of the size
involved, the taxpayer's applicable percentage shall be 2
percent.
``(iii) Indexing.--In the case of taxable years beginning
in any calendar year after 2014, the Secretary shall adjust
the initial and final applicable percentages under clause
(i), and the 2 percent under clause (ii), for the calendar
year to reflect the excess of the rate of premium growth
between the preceding calendar year and 2013 over the rate of
income growth for such period.
``(B) Applicable second lowest cost silver plan.--The
applicable second lowest cost silver plan with respect to any
applicable taxpayer is the second lowest cost silver plan of
the individual market in the rating area in which the
taxpayer resides which--
``(i) is offered through the same Exchange through which
the qualified health plans taken into account under paragraph
(2)(A) were offered, and
``(ii) provides--
``(I) self-only coverage in the case of an applicable
taxpayer--
``(aa) whose tax for the taxable year is determined under
section 1(c) (relating to unmarried individuals other than
surviving spouses and heads of households) and who is not
allowed a deduction under section 151 for the taxable year
with respect to a dependent, or
``(bb) who is not described in item (aa) but who purchases
only self-only coverage, and
``(II) family coverage in the case of any other applicable
taxpayer.
If a taxpayer files a joint return and no credit is allowed
under this section with respect to 1 of the spouses by reason
of subsection (e), the taxpayer shall be treated as described
in clause (ii)(I) unless a deduction is allowed under section
151 for the taxable year with respect to a dependent other
than either spouse and subsection (e) does not apply to the
dependent.
``(C) Adjusted monthly premium.--The adjusted monthly
premium for an applicable second lowest cost silver plan is
the monthly premium which would have been charged (for the
rating area with respect to which the premiums under
paragraph (2)(A) were determined) for the plan if each
individual covered under a qualified health plan taken into
account under paragraph (2)(A) were covered by such silver
plan and the premium was adjusted only for the age of each
such individual in the manner allowed under section 2701 of
the Public Health Service Act. In the case of a State
participating in the wellness discount demonstration project
under section 2705(d) of the Public Health Service Act, the
adjusted monthly premium shall be determined without regard
to any premium discount or rebate under such project.
``(D) Additional benefits.--If--
``(i) a qualified health plan under section 1302(b)(5) of
the Patient Protection and Affordable Care Act offers
benefits in addition to the essential health benefits
required to be provided by the plan, or
``(ii) a State requires a qualified health plan under
section 1311(d)(3)(B) of such Act to cover benefits in
addition to the essential health benefits required to be
provided by the plan,
the portion of the premium for the plan properly allocable
(under rules prescribed by the Secretary of Health and Human
Services) to such additional benefits shall not be taken into
account in determining either the monthly premium or the
adjusted monthly premium under paragraph (2).
``(E) Special rule for pediatric dental coverage.--For
purposes of determining the amount of any monthly premium, if
an individual enrolls in both a qualified health plan and a
plan described in section 1311(d)(2)(B)(ii)(I) of the Patient
Protection and Affordable Care Act for any plan year, the
portion of the premium for the plan described in such section
that (under regulations prescribed by the Secretary) is
properly allocable to pediatric dental benefits which are
included in the essential health benefits required to be
provided by a qualified health plan under section
1302(b)(1)(J) of such Act shall be treated as a premium
payable for a qualified health plan.
``(c) Definition and Rules Relating to Applicable
Taxpayers, Coverage Months, and Qualified Health Plan.--For
purposes of this section--
``(1) Applicable taxpayer.--
``(A) In general.--The term `applicable taxpayer' means,
with respect to any taxable year, a taxpayer whose household
income for the taxable year exceeds 100 percent but does not
exceed 400 percent of an amount equal to the poverty line for
a family of the size involved.
``(B) Special rule for certain individuals lawfully present
in the united states.--If--
``(i) a taxpayer has a household income which is not
greater than 100 percent of an amount equal to the poverty
line for a family of the size involved, and
``(ii) the taxpayer is an alien lawfully present in the
United States, but is not eligible for the medicaid program
under title XIX of the Social Security Act by reason of such
alien status,
the taxpayer shall, for purposes of the credit under this
section, be treated as an applicable taxpayer with a
household income which is equal to 100 percent of the poverty
line for a family of the size involved.
``(C) Married couples must file joint return.--If the
taxpayer is married (within the meaning of section 7703) at
the close of the taxable year, the taxpayer shall be treated
as an applicable taxpayer only if the taxpayer and the
taxpayer's spouse file a joint return for the taxable year.
``(D) Denial of credit to dependents.--No credit shall be
allowed under this section to any individual with respect to
whom a deduction under section 151 is allowable to another
taxpayer for a taxable year beginning in the calendar year in
which such individual's taxable year begins.
``(2) Coverage month.--For purposes of this subsection--
``(A) In general.--The term `coverage month' means, with
respect to an applicable taxpayer, any month if--
``(i) as of the first day of such month the taxpayer, the
taxpayer's spouse, or any dependent of the taxpayer is
covered by a qualified health plan described in subsection
(b)(2)(A) that was enrolled in through an Exchange
established by the State under section 1311 of the Patient
Protection and Affordable Care Act, and
``(ii) the premium for coverage under such plan for such
month is paid by the taxpayer (or through advance payment of
the credit under subsection (a) under section 1412 of the
Patient Protection and Affordable Care Act).
``(B) Exception for minimum essential coverage.--
``(i) In general.--The term `coverage month' shall not
include any month with respect to an individual if for such
month the individual is eligible for minimum essential
coverage other than eligibility for coverage described in
section 5000A(f)(1)(C) (relating to coverage in the
individual market).
``(ii) Minimum essential coverage.--The term `minimum
essential coverage' has the meaning given such term by
section 5000A(f).
``(C) Special rule for employer-sponsored minimum essential
coverage.--For purposes of subparagraph (B)--
``(i) Coverage must be affordable.--Except as provided in
clause (iii), an employee shall not be treated as eligible
for minimum essential coverage if such coverage--
``(I) consists of an eligible employer-sponsored plan (as
defined in section 5000A(f)(2)), and
``(II) the employee's required contribution (within the
meaning of section 5000A(e)(1)(B)) with respect to the plan
exceeds 9.8 percent of the applicable taxpayer's household
income.
This clause shall also apply to an individual who is eligible
to enroll in the plan by reason of a relationship the
individual bears to the employee.
``(ii) Coverage must provide minimum value.--Except as
provided in clause (iii), an employee shall not be treated as
eligible for minimum essential coverage if such coverage
consists of an eligible employer-sponsored plan (as
[[Page H1947]]
defined in section 5000A(f)(2)) and the plan's share of the
total allowed costs of benefits provided under the plan is
less than 60 percent of such costs.
``(iii) Employee or family must not be covered under
employer plan.--Clauses (i) and (ii) shall not apply if the
employee (or any individual described in the last sentence of
clause (i)) is covered under the eligible employer-sponsored
plan or the grandfathered health plan.
``(iv) Indexing.--In the case of plan years beginning in
any calendar year after 2014, the Secretary shall adjust the
9.8 percent under clause (i)(II) in the same manner as the
percentages are adjusted under subsection (b)(3)(A)(ii).
``(3) Definitions and other rules.--
``(A) Qualified health plan.--The term `qualified health
plan' has the meaning given such term by section 1301(a) of
the Patient Protection and Affordable Care Act, except that
such term shall not include a qualified health plan which is
a catastrophic plan described in section 1302(e) of such Act.
``(B) Grandfathered health plan.--The term `grandfathered
health plan' has the meaning given such term by section 1251
of the Patient Protection and Affordable Care Act.
``(d) Terms Relating to Income and Families.--For purposes
of this section--
``(1) Family size.--The family size involved with respect
to any taxpayer shall be equal to the number of individuals
for whom the taxpayer is allowed a deduction under section
151 (relating to allowance of deduction for personal
exemptions) for the taxable year.
``(2) Household income.--
``(A) Household income.--The term `household income' means,
with respect to any taxpayer, an amount equal to the sum of--
``(i) the modified gross income of the taxpayer, plus
``(ii) the aggregate modified gross incomes of all other
individuals who--
``(I) were taken into account in determining the taxpayer's
family size under paragraph (1), and
``(II) were required to file a return of tax imposed by
section 1 for the taxable year.
``(B) Modified gross income.--The term `modified gross
income' means gross income--
``(i) decreased by the amount of any deduction allowable
under paragraph (1), (3), (4), or (10) of section 62(a),
``(ii) increased by the amount of interest received or
accrued during the taxable year which is exempt from tax
imposed by this chapter, and
``(iii) determined without regard to sections 911, 931, and
933.
``(3) Poverty line.--
``(A) In general.--The term `poverty line' has the meaning
given that term in section 2110(c)(5) of the Social Security
Act (42 U.S.C. 1397jj(c)(5)).
``(B) Poverty line used.--In the case of any qualified
health plan offered through an Exchange for coverage during a
taxable year beginning in a calendar year, the poverty line
used shall be the most recently published poverty line as of
the 1st day of the regular enrollment period for coverage
during such calendar year.
``(e) Rules for Individuals Not Lawfully Present.--
``(1) In general.--If 1 or more individuals for whom a
taxpayer is allowed a deduction under section 151 (relating
to allowance of deduction for personal exemptions) for the
taxable year (including the taxpayer or his spouse) are
individuals who are not lawfully present--
``(A) the aggregate amount of premiums otherwise taken into
account under clauses (i) and (ii) of subsection (b)(2)(A)
shall be reduced by the portion (if any) of such premiums
which is attributable to such individuals, and
``(B) for purposes of applying this section, the
determination as to what percentage a taxpayer's household
income bears to the poverty level for a family of the size
involved shall be made under one of the following methods:
``(i) A method under which--
``(I) the taxpayer's family size is determined by not
taking such individuals into account, and
``(II) the taxpayer's household income is equal to the
product of the taxpayer's household income (determined
without regard to this subsection) and a fraction--
``(aa) the numerator of which is the poverty line for the
taxpayer's family size determined after application of
subclause (I), and
``(bb) the denominator of which is the poverty line for the
taxpayer's family size determined without regard to subclause
(I).
``(ii) A comparable method reaching the same result as the
method under clause (i).
``(2) Lawfully present.--For purposes of this section, an
individual shall be treated as lawfully present only if the
individual is, and is reasonably expected to be for the
entire period of enrollment for which the credit under this
section is being claimed, a citizen or national of the United
States or an alien lawfully present in the United States.
``(3) Secretarial authority.--The Secretary of Health and
Human Services, in consultation with the Secretary, shall
prescribe rules setting forth the methods by which
calculations of family size and household income are made for
purposes of this subsection. Such rules shall be designed to
ensure that the least burden is placed on individuals
enrolling in qualified health plans through an Exchange and
taxpayers eligible for the credit allowable under this
section.
``(f) Reconciliation of Credit and Advance Credit.--
``(1) In general.--The amount of the credit allowed under
this section for any taxable year shall be reduced (but not
below zero) by the amount of any advance payment of such
credit under section 1412 of the Patient Protection and
Affordable Care Act.
``(2) Excess advance payments.--
``(A) In general.--If the advance payments to a taxpayer
under section 1412 of the Patient Protection and Affordable
Care Act for a taxable year exceed the credit allowed by this
section (determined without regard to paragraph (1)), the tax
imposed by this chapter for the taxable year shall be
increased by the amount of such excess.
``(B) Limitation on increase where income less than 400
percent of poverty line.--
``(i) In general.--In the case of an applicable taxpayer
whose household income is less than 400 percent of the
poverty line for the size of the family involved for the
taxable year, the amount of the increase under subparagraph
(A) shall in no event exceed $400 ($250 in the case of a
taxpayer whose tax is determined under section 1(c) for the
taxable year).
``(ii) Indexing of amount.--In the case of any calendar
year beginning after 2014, each of the dollar amounts under
clause (i) shall be increased by an amount equal to--
``(I) such dollar amount, multiplied by
``(II) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year, determined by
substituting `calendar year 2013' for `calendar year 1992' in
subparagraph (B) thereof.
If the amount of any increase under clause (i) is not a
multiple of $50, such increase shall be rounded to the next
lowest multiple of $50.
``(g) Regulations.--The Secretary shall prescribe such
regulations as may be necessary to carry out the provisions
of this section, including regulations which provide for--
``(1) the coordination of the credit allowed under this
section with the program for advance payment of the credit
under section 1412 of the Patient Protection and Affordable
Care Act, and
``(2) the application of subsection (f) where the filing
status of the taxpayer for a taxable year is different from
such status used for determining the advance payment of the
credit.''.
(b) Disallowance of Deduction.--Section 280C of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new subsection:
``(g) Credit for Health Insurance Premiums.--No deduction
shall be allowed for the portion of the premiums paid by the
taxpayer for coverage of 1 or more individuals under a
qualified health plan which is equal to the amount of the
credit determined for the taxable year under section 36B(a)
with respect to such premiums.''.
(c) Study on Affordable Coverage.--
(1) Study and report.--
(A) In general.--Not later than 5 years after the date of
the enactment of this Act, the Comptroller General shall
conduct a study on the affordability of health insurance
coverage, including--
(i) the impact of the tax credit for qualified health
insurance coverage of individuals under section 36B of the
Internal Revenue Code of 1986 and the tax credit for employee
health insurance expenses of small employers under section
45R of such Code on maintaining and expanding the health
insurance coverage of individuals;
(ii) the availability of affordable health benefits plans,
including a study of whether the percentage of household
income used for purposes of section 36B(c)(2)(C) of the
Internal Revenue Code of 1986 (as added by this section) is
the appropriate level for determining whether employer-
provided coverage is affordable for an employee and whether
such level may be lowered without significantly increasing
the costs to the Federal Government and reducing employer-
provided coverage; and
(iii) the ability of individuals to maintain essential
health benefits coverage (as defined in section 5000A(f) of
the Internal Revenue Code of 1986).
(B) Report.--The Comptroller General shall submit to the
appropriate committees of Congress a report on the study
conducted under subparagraph (A), together with legislative
recommendations relating to the matters studied under such
subparagraph.
(2) Appropriate committees of congress.--In this
subsection, the term ``appropriate committees of Congress''
means the Committee on Ways and Means, the Committee on
Education and Labor, and the Committee on Energy and Commerce
of the House of Representatives and the Committee on Finance
and the Committee on Health, Education, Labor and Pensions of
the Senate.
(d) Conforming Amendments.--
(1) Paragraph (2) of section 1324(b) of title 31, United
States Code, is amended by inserting ``36B,'' after ``36A,''.
(2) The table of sections for subpart C of part IV of
subchapter A of chapter 1 of the Internal Revenue Code of
1986 is amended by inserting after the item relating to
section 36A the following new item:
``Sec. 36B. Refundable credit for coverage under a qualified health
plan.''.
(e) Effective Date.--The amendments made by this section
shall apply to taxable years ending after December 31, 2013.
SEC. 1402. REDUCED COST-SHARING FOR INDIVIDUALS ENROLLING IN
QUALIFIED HEALTH PLANS.
(a) In General.--In the case of an eligible insured
enrolled in a qualified health plan--
(1) the Secretary shall notify the issuer of the plan of
such eligibility; and
(2) the issuer shall reduce the cost-sharing under the plan
at the level and in the manner specified in subsection (c).
(b) Eligible Insured.--In this section, the term ``eligible
insured'' means an individual--
(1) who enrolls in a qualified health plan in the silver
level of coverage in the individual market offered through an
Exchange; and
(2) whose household income exceeds 100 percent but does not
exceed 400 percent of the poverty line for a family of the
size involved.
[[Page H1948]]
In the case of an individual described in section
36B(c)(1)(B) of the Internal Revenue Code of 1986, the
individual shall be treated as having household income equal
to 100 percent for purposes of applying this section.
(c) Determination of Reduction in Cost-sharing.--
(1) Reduction in out-of-pocket limit.--
(A) In general.--The reduction in cost-sharing under this
subsection shall first be achieved by reducing the applicable
out-of pocket limit under section 1302(c)(1) in the case of--
(i) an eligible insured whose household income is more than
100 percent but not more than 200 percent of the poverty line
for a family of the size involved, by two-thirds;
(ii) an eligible insured whose household income is more
than 200 percent but not more than 300 percent of the poverty
line for a family of the size involved, by one-half; and
(iii) an eligible insured whose household income is more
than 300 percent but not more than 400 percent of the poverty
line for a family of the size involved, by one-third.
(B) Coordination with actuarial value limits.--
(i) In general.--The Secretary shall ensure the reduction
under this paragraph shall not result in an increase in the
plan's share of the total allowed costs of benefits provided
under the plan above--
(I) 90 percent in the case of an eligible insured described
in paragraph (2)(A);
(II) 80 percent in the case of an eligible insured
described in paragraph (2)(B); and
(III) 70 percent in the case of an eligible insured
described in clause (ii) or (iii) of subparagraph (A).
(ii) Adjustment.--The Secretary shall adjust the out-of
pocket limits under paragraph (1) if necessary to ensure that
such limits do not cause the respective actuarial values to
exceed the levels specified in clause (i).
(2) Additional reduction for lower income insureds.--The
Secretary shall establish procedures under which the issuer
of a qualified health plan to which this section applies
shall further reduce cost-sharing under the plan in a manner
sufficient to--
(A) in the case of an eligible insured whose household
income is not less than 100 percent but not more than 150
percent of the poverty line for a family of the size
involved, increase the plan's share of the total allowed
costs of benefits provided under the plan to 90 percent of
such costs; and
(B) in the case of an eligible insured whose household
income is more than 150 percent but not more than 200 percent
of the poverty line for a family of the size involved,
increase the plan's share of the total allowed costs of
benefits provided under the plan to 80 percent of such costs.
(3) Methods for reducing cost-sharing.--
(A) In general.--An issuer of a qualified health plan
making reductions under this subsection shall notify the
Secretary of such reductions and the Secretary shall make
periodic and timely payments to the issuer equal to the value
of the reductions.
(B) Capitated payments.--The Secretary may establish a
capitated payment system to carry out the payment of cost-
sharing reductions under this section. Any such system shall
take into account the value of the reductions and make
appropriate risk adjustments to such payments.
(4) Additional benefits.--If a qualified health plan under
section 1302(b)(5) offers benefits in addition to the
essential health benefits required to be provided by the
plan, or a State requires a qualified health plan under
section 1311(d)(3)(B) to cover benefits in addition to the
essential health benefits required to be provided by the
plan, the reductions in cost-sharing under this section shall
not apply to such additional benefits.
(5) Special rule for pediatric dental plans.--If an
individual enrolls in both a qualified health plan and a plan
described in section 1311(d)(2)(B)(ii)(I) for any plan year,
subsection (a) shall not apply to that portion of any
reduction in cost-sharing under subsection (c) that (under
regulations prescribed by the Secretary) is properly
allocable to pediatric dental benefits which are included in
the essential health benefits required to be provided by a
qualified health plan under section 1302(b)(1)(J).
(d) Special Rules for Indians.--
(1) Indians under 300 percent of poverty.--If an individual
enrolled in any qualified health plan in the individual
market through an Exchange is an Indian (as defined in
section 4(d) of the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450b(d))) whose household income is
not more than 300 percent of the poverty line for a family of
the size involved, then, for purposes of this section--
(A) such individual shall be treated as an eligible
insured; and
(B) the issuer of the plan shall eliminate any cost-sharing
under the plan.
(2) Items or services furnished through indian health
providers.--If an Indian (as so defined) enrolled in a
qualified health plan is furnished an item or service
directly by the Indian Health Service, an Indian Tribe,
Tribal Organization, or Urban Indian Organization or through
referral under contract health services--
(A) no cost-sharing under the plan shall be imposed under
the plan for such item or service; and
(B) the issuer of the plan shall not reduce the payment to
any such entity for such item or service by the amount of any
cost-sharing that would be due from the Indian but for
subparagraph (A).
(3) Payment.--The Secretary shall pay to the issuer of a
qualified health plan the amount necessary to reflect the
increase in actuarial value of the plan required by reason of
this subsection.
(e) Rules for Individuals Not Lawfully Present.--
(1) In general.--If an individual who is an eligible
insured is not lawfully present--
(A) no cost-sharing reduction under this section shall
apply with respect to the individual; and
(B) for purposes of applying this section, the
determination as to what percentage a taxpayer's household
income bears to the poverty level for a family of the size
involved shall be made under one of the following methods:
(i) A method under which--
(I) the taxpayer's family size is determined by not taking
such individuals into account, and
(II) the taxpayer's household income is equal to the
product of the taxpayer's household income (determined
without regard to this subsection) and a fraction--
(aa) the numerator of which is the poverty line for the
taxpayer's family size determined after application of
subclause (I), and
(bb) the denominator of which is the poverty line for the
taxpayer's family size determined without regard to subclause
(I).
(ii) A comparable method reaching the same result as the
method under clause (i).
(2) Lawfully present.--For purposes of this section, an
individual shall be treated as lawfully present only if the
individual is, and is reasonably expected to be for the
entire period of enrollment for which the cost-sharing
reduction under this section is being claimed, a citizen or
national of the United States or an alien lawfully present in
the United States.
(3) Secretarial authority.--The Secretary, in consultation
with the Secretary of the Treasury, shall prescribe rules
setting forth the methods by which calculations of family
size and household income are made for purposes of this
subsection. Such rules shall be designed to ensure that the
least burden is placed on individuals enrolling in qualified
health plans through an Exchange and taxpayers eligible for
the credit allowable under this section.
(f) Definitions and Special Rules.--In this section:
(1) In general.--Any term used in this section which is
also used in section 36B of the Internal Revenue Code of 1986
shall have the meaning given such term by such section.
(2) Limitations on reduction.--No cost-sharing reduction
shall be allowed under this section with respect to coverage
for any month unless the month is a coverage month with
respect to which a credit is allowed to the insured (or an
applicable taxpayer on behalf of the insured) under section
36B of such Code.
(3) Data used for eligibility.--Any determination under
this section shall be made on the basis of the taxable year
for which the advance determination is made under section
1412 and not the taxable year for which the credit under
section 36B of such Code is allowed.
Subpart B--Eligibility Determinations
SEC. 1411. PROCEDURES FOR DETERMINING ELIGIBILITY FOR
EXCHANGE PARTICIPATION, PREMIUM TAX CREDITS AND
REDUCED COST-SHARING, AND INDIVIDUAL
RESPONSIBILITY EXEMPTIONS.
(a) Establishment of Program.--The Secretary shall
establish a program meeting the requirements of this section
for determining--
(1) whether an individual who is to be covered in the
individual market by a qualified health plan offered through
an Exchange, or who is claiming a premium tax credit or
reduced cost-sharing, meets the requirements of sections
1312(f)(3), 1402(e), and 1412(d) of this title and section
36B(e) of the Internal Revenue Code of 1986 that the
individual be a citizen or national of the United States or
an alien lawfully present in the United States;
(2) in the case of an individual claiming a premium tax
credit or reduced cost-sharing under section 36B of such Code
or section 1402--
(A) whether the individual meets the income and coverage
requirements of such sections; and
(B) the amount of the tax credit or reduced cost-sharing;
(3) whether an individual's coverage under an employer-
sponsored health benefits plan is treated as unaffordable
under sections 36B(c)(2)(C) and 5000A(e)(2); and
(4) whether to grant a certification under section
1311(d)(4)(H) attesting that, for purposes of the individual
responsibility requirement under section 5000A of the
Internal Revenue Code of 1986, an individual is entitled to
an exemption from either the individual responsibility
requirement or the penalty imposed by such section.
(b) Information Required To Be Provided by Applicants.--
(1) In general.--An applicant for enrollment in a qualified
health plan offered through an Exchange in the individual
market shall provide--
(A) the name, address, and date of birth of each individual
who is to be covered by the plan (in this subsection referred
to as an ``enrollee''); and
(B) the information required by any of the following
paragraphs that is applicable to an enrollee.
(2) Citizenship or immigration status.--The following
information shall be provided with respect to every enrollee:
(A) In the case of an enrollee whose eligibility is based
on an attestation of citizenship of the enrollee, the
enrollee's social security number.
(B) In the case of an individual whose eligibility is based
on an attestation of the enrollee's immigration status, the
enrollee's social security number (if applicable) and such
identifying information with respect to the enrollee's
immigration status as the Secretary, after consultation with
the Secretary of Homeland Security, determines appropriate.
(3) Eligibility and amount of tax credit or reduced cost-
sharing.--In the case of an enrollee with respect to whom a
premium tax credit or reduced cost-sharing under section 36B
[[Page H1949]]
of such Code or section 1402 is being claimed, the following
information:
(A) Information regarding income and family size.--The
information described in section 6103(l)(21) for the taxable
year ending with or within the second calendar year preceding
the calendar year in which the plan year begins.
(B) Changes in circumstances.--The information described in
section 1412(b)(2), including information with respect to
individuals who were not required to file an income tax
return for the taxable year described in subparagraph (A) or
individuals who experienced changes in marital status or
family size or significant reductions in income.
(4) Employer-sponsored coverage.--In the case of an
enrollee with respect to whom eligibility for a premium tax
credit under section 36B of such Code or cost-sharing
reduction under section 1402 is being established on the
basis that the enrollee's (or related individual's) employer
is not treated under section 36B(c)(2)(C) of such Code as
providing minimum essential coverage or affordable minimum
essential coverage, the following information:
(A) The name, address, and employer identification number
(if available) of the employer.
(B) Whether the enrollee or individual is a full-time
employee and whether the employer provides such minimum
essential coverage.
(C) If the employer provides such minimum essential
coverage, the lowest cost option for the enrollee's or
individual's enrollment status and the enrollee's or
individual's required contribution (within the meaning of
section 5000A(e)(1)(B) of such Code) under the employer-
sponsored plan.
(D) If an enrollee claims an employer's minimum essential
coverage is unaffordable, the information described in
paragraph (3).
If an enrollee changes employment or obtains additional
employment while enrolled in a qualified health plan for
which such credit or reduction is allowed, the enrollee shall
notify the Exchange of such change or additional employment
and provide the information described in this paragraph with
respect to the new employer.
(5) Exemptions from individual responsibility
requirements.--In the case of an individual who is seeking an
exemption certificate under section 1311(d)(4)(H) from any
requirement or penalty imposed by section 5000A, the
following information:
(A) In the case of an individual seeking exemption based on
the individual's status as a member of an exempt religious
sect or division, as a member of a health care sharing
ministry, as an Indian, or as an individual eligible for a
hardship exemption, such information as the Secretary shall
prescribe.
(B) In the case of an individual seeking exemption based on
the lack of affordable coverage or the individual's status as
a taxpayer with household income less than 100 percent of the
poverty line, the information described in paragraphs (3) and
(4), as applicable.
(c) Verification of Information Contained in Records of
Specific Federal Officials.--
(1) Information transferred to secretary.--An Exchange
shall submit the information provided by an applicant under
subsection (b) to the Secretary for verification in
accordance with the requirements of this subsection and
subsection (d).
(2) Citizenship or immigration status.--
(A) Commissioner of social security.--The Secretary shall
submit to the Commissioner of Social Security the following
information for a determination as to whether the information
provided is consistent with the information in the records of
the Commissioner:
(i) The name, date of birth, and social security number of
each individual for whom such information was provided under
subsection (b)(2).
(ii) The attestation of an individual that the individual
is a citizen.
(B) Secretary of homeland security.--
(i) In general.--In the case of an individual--
(I) who attests that the individual is an alien lawfully
present in the United States; or
(II) who attests that the individual is a citizen but with
respect to whom the Commissioner of Social Security has
notified the Secretary under subsection (e)(3) that the
attestation is inconsistent with information in the records
maintained by the Commissioner;
the Secretary shall submit to the Secretary of Homeland
Security the information described in clause (ii) for a
determination as to whether the information provided is
consistent with the information in the records of the
Secretary of Homeland Security.
(ii) Information.--The information described in clause (ii)
is the following:
(I) The name, date of birth, and any identifying
information with respect to the individual's immigration
status provided under subsection (b)(2).
(II) The attestation that the individual is an alien
lawfully present in the United States or in the case of an
individual described in clause (i)(II), the attestation that
the individual is a citizen.
(3) Eligibility for tax credit and cost-sharing
reduction.--The Secretary shall submit the information
described in subsection (b)(3)(A) provided under paragraph
(3), (4), or (5) of subsection (b) to the Secretary of the
Treasury for verification of household income and family size
for purposes of eligibility.
(4) Methods.--
(A) In general.--The Secretary, in consultation with the
Secretary of the Treasury, the Secretary of Homeland
Security, and the Commissioner of Social Security, shall
provide that verifications and determinations under this
subsection shall be done--
(i) through use of an on-line system or otherwise for the
electronic submission of, and response to, the information
submitted under this subsection with respect to an applicant;
or
(ii) by determining the consistency of the information
submitted with the information maintained in the records of
the Secretary of the Treasury, the Secretary of Homeland
Security, or the Commissioner of Social Security through such
other method as is approved by the Secretary.
(B) Flexibility.--The Secretary may modify the methods used
under the program established by this section for the
Exchange and verification of information if the Secretary
determines such modifications would reduce the administrative
costs and burdens on the applicant, including allowing an
applicant to request the Secretary of the Treasury to provide
the information described in paragraph (3) directly to the
Exchange or to the Secretary. The Secretary shall not make
any such modification unless the Secretary determines that
any applicable requirements under this section and section
6103 of the Internal Revenue Code of 1986 with respect to the
confidentiality, disclosure, maintenance, or use of
information will be met.
(d) Verification by Secretary.--In the case of information
provided under subsection (b) that is not required under
subsection (c) to be submitted to another person for
verification, the Secretary shall verify the accuracy of such
information in such manner as the Secretary determines
appropriate, including delegating responsibility for
verification to the Exchange.
(e) Actions Relating to Verification.--
(1) In general.--Each person to whom the Secretary provided
information under subsection (c) shall report to the
Secretary under the method established under subsection
(c)(4) the results of its verification and the Secretary
shall notify the Exchange of such results. Each person to
whom the Secretary provided information under subsection (d)
shall report to the Secretary in such manner as the Secretary
determines appropriate.
(2) Verification.--
(A) Eligibility for enrollment and premium tax credits and
cost-sharing reductions.--If information provided by an
applicant under paragraphs (1), (2), (3), and (4) of
subsection (b) is verified under subsections (c) and (d)--
(i) the individual's eligibility to enroll through the
Exchange and to apply for premium tax credits and cost-
sharing reductions shall be satisfied; and
(ii) the Secretary shall, if applicable, notify the
Secretary of the Treasury under section 1412(c) of the amount
of any advance payment to be made.
(B) Exemption from individual responsibility.--If
information provided by an applicant under subsection (b)(5)
is verified under subsections (c) and (d), the Secretary
shall issue the certification of exemption described in
section 1311(d)(4)(H).
(3) Inconsistencies involving attestation of citizenship or
lawful presence.--If the information provided by any
applicant under subsection (b)(2) is inconsistent with
information in the records maintained by the Commissioner of
Social Security or Secretary of Homeland Security, whichever
is applicable, the applicant's eligibility will be determined
in the same manner as an individual's eligibility under the
medicaid program is determined under section 1902(ee) of the
Social Security Act (as in effect on January 1, 2010).
(4) Inconsistencies involving other information.--
(A) In general.--If the information provided by an
applicant under subsection (b) (other than subsection (b)(2))
is inconsistent with information in the records maintained by
persons under subsection (c) or is not verified under
subsection (d), the Secretary shall notify the Exchange and
the Exchange shall take the following actions:
(i) Reasonable effort.--The Exchange shall make a
reasonable effort to identify and address the causes of such
inconsistency, including through typographical or other
clerical errors, by contacting the applicant to confirm the
accuracy of the information, and by taking such additional
actions as the Secretary, through regulation or other
guidance, may identify.
(ii) Notice and opportunity to correct.--In the case the
inconsistency or inability to verify is not resolved under
subparagraph (A), the Exchange shall--
(I) notify the applicant of such fact;
(II) provide the applicant an opportunity to either present
satisfactory documentary evidence or resolve the
inconsistency with the person verifying the information under
subsection (c) or (d) during the 90-day period beginning the
date on which the notice required under subclause (I) is sent
to the applicant.
The Secretary may extend the 90-day period under subclause
(II) for enrollments occurring during 2014.
(B) Specific actions not involving citizenship or lawful
presence.--
(i) In general.--Except as provided in paragraph (3), the
Exchange shall, during any period before the close of the
period under subparagraph (A)(ii)(II), make any determination
under paragraphs (2), (3), and (4) of subsection (a) on the
basis of the information contained on the application.
(ii) Eligibility or amount of credit or reduction.--If an
inconsistency involving the eligibility for, or amount of,
any premium tax credit or cost-sharing reduction is
unresolved under this subsection as of the close of the
period under subparagraph (A)(ii)(II), the Exchange shall
notify the applicant of the amount (if any) of the credit or
reduction that is determined on the basis of the records
maintained by persons under subsection (c).
(iii) Employer affordability.--If the Secretary notifies an
Exchange that an enrollee is
[[Page H1950]]
eligible for a premium tax credit under section 36B of such
Code or cost-sharing reduction under section 1402 because the
enrollee's (or related individual's) employer does not
provide minimum essential coverage through an employer-
sponsored plan or that the employer does provide that
coverage but it is not affordable coverage, the Exchange
shall notify the employer of such fact and that the employer
may be liable for the payment assessed under section 4980H of
such Code.
(iv) Exemption.--In any case where the inconsistency
involving, or inability to verify, information provided under
subsection (b)(5) is not resolved as of the close of the
period under subparagraph (A)(ii)(II), the Exchange shall
notify an applicant that no certification of exemption from
any requirement or payment under section 5000A of such Code
will be issued.
(C) Appeals process.--The Exchange shall also notify each
person receiving notice under this paragraph of the appeals
processes established under subsection (f).
(f) Appeals and Redeterminations.--
(1) In general.--The Secretary, in consultation with the
Secretary of the Treasury, the Secretary of Homeland
Security, and the Commissioner of Social Security, shall
establish procedures by which the Secretary or one of such
other Federal officers--
(A) hears and makes decisions with respect to appeals of
any determination under subsection (e); and
(B) redetermines eligibility on a periodic basis in
appropriate circumstances.
(2) Employer liability.--
(A) In general.--The Secretary shall establish a separate
appeals process for employers who are notified under
subsection (e)(4)(C) that the employer may be liable for a
tax imposed by section 4980H of the Internal Revenue Code of
1986 with respect to an employee because of a determination
that the employer does not provide minimum essential coverage
through an employer-sponsored plan or that the employer does
provide that coverage but it is not affordable coverage with
respect to an employee. Such process shall provide an
employer the opportunity to--
(i) present information to the Exchange for review of the
determination either by the Exchange or the person making the
determination, including evidence of the employer-sponsored
plan and employer contributions to the plan; and
(ii) have access to the data used to make the determination
to the extent allowable by law.
Such process shall be in addition to any rights of appeal the
employer may have under subtitle F of such Code.
(B) Confidentiality.--Notwithstanding any provision of this
title (or the amendments made by this title) or section 6103
of the Internal Revenue Code of 1986, an employer shall not
be entitled to any taxpayer return information with respect
to an employee for purposes of determining whether the
employer is subject to the penalty under section 4980H of
such Code with respect to the employee, except that--
(i) the employer may be notified as to the name of an
employee and whether or not the employee's income is above or
below the threshold by which the affordability of an
employer's health insurance coverage is measured; and
(ii) this subparagraph shall not apply to an employee who
provides a waiver (at such time and in such manner as the
Secretary may prescribe) authorizing an employer to have
access to the employee's taxpayer return information.
(g) Confidentiality of Applicant Information.--
(1) In general.--An applicant for insurance coverage or for
a premium tax credit or cost-sharing reduction shall be
required to provide only the information strictly necessary
to authenticate identity, determine eligibility, and
determine the amount of the credit or reduction.
(2) Receipt of information.--Any person who receives
information provided by an applicant under subsection (b)
(whether directly or by another person at the request of the
applicant), or receives information from a Federal agency
under subsection (c), (d), or (e), shall--
(A) use the information only for the purposes of, and to
the extent necessary in, ensuring the efficient operation of
the Exchange, including verifying the eligibility of an
individual to enroll through an Exchange or to claim a
premium tax credit or cost-sharing reduction or the amount of
the credit or reduction; and
(B) not disclose the information to any other person except
as provided in this section.
(h) Penalties.--
(1) False or fraudulent information.--
(A) Civil penalty.--
(i) In general.--If--
(I) any person fails to provides correct information under
subsection (b); and
(II) such failure is attributable to negligence or
disregard of any rules or regulations of the Secretary,
such person shall be subject, in addition to any other
penalties that may be prescribed by law, to a civil penalty
of not more than $25,000 with respect to any failures
involving an application for a plan year. For purposes of
this subparagraph, the terms ``negligence'' and ``disregard''
shall have the same meanings as when used in section 6662 of
the Internal Revenue Code of 1986.
(ii) Reasonable cause exception.--No penalty shall be
imposed under clause (i) if the Secretary determines that
there was a reasonable cause for the failure and that the
person acted in good faith.
(B) Knowing and willful violations.--Any person who
knowingly and willfully provides false or fraudulent
information under subsection (b) shall be subject, in
addition to any other penalties that may be prescribed by
law, to a civil penalty of not more than $250,000.
(2) Improper use or disclosure of information.--Any person
who knowingly and willfully uses or discloses information in
violation of subsection (g) shall be subject, in addition to
any other penalties that may be prescribed by law, to a civil
penalty of not more than $25,000.
(3) Limitations on liens and levies.--The Secretary (or, if
applicable, the Attorney General of the United States) shall
not--
(A) file notice of lien with respect to any property of a
person by reason of any failure to pay the penalty imposed by
this subsection; or
(B) levy on any such property with respect to such failure.
(i) Study of Administration of Employer Responsibility.--
(1) In general.--The Secretary of Health and Human Services
shall, in consultation with the Secretary of the Treasury,
conduct a study of the procedures that are necessary to
ensure that in the administration of this title and section
4980H of the Internal Revenue Code of 1986 (as added by
section 1513) that the following rights are protected:
(A) The rights of employees to preserve their right to
confidentiality of their taxpayer return information and
their right to enroll in a qualified health plan through an
Exchange if an employer does not provide affordable coverage.
(B) The rights of employers to adequate due process and
access to information necessary to accurately determine any
payment assessed on employers.
(2) Report.--Not later than January 1, 2013, the Secretary
of Health and Human Services shall report the results of the
study conducted under paragraph (1), including any
recommendations for legislative changes, to the Committees on
Finance and Health, Education, Labor and Pensions of the
Senate and the Committees of Education and Labor and Ways and
Means of the House of Representatives.
SEC. 1412. ADVANCE DETERMINATION AND PAYMENT OF PREMIUM TAX
CREDITS AND COST-SHARING REDUCTIONS.
(a) In General.--The Secretary, in consultation with the
Secretary of the Treasury, shall establish a program under
which--
(1) upon request of an Exchange, advance determinations are
made under section 1411 with respect to the income
eligibility of individuals enrolling in a qualified health
plan in the individual market through the Exchange for the
premium tax credit allowable under section 36B of the
Internal Revenue Code of 1986 and the cost-sharing reductions
under section 1402;
(2) the Secretary notifies--
(A) the Exchange and the Secretary of the Treasury of the
advance determinations; and
(B) the Secretary of the Treasury of the name and employer
identification number of each employer with respect to whom 1
or more employee of the employer were determined to be
eligible for the premium tax credit under section 36B of the
Internal Revenue Code of 1986 and the cost-sharing reductions
under section 1402 because--
(i) the employer did not provide minimum essential
coverage; or
(ii) the employer provided such minimum essential coverage
but it was determined under section 36B(c)(2)(C) of such Code
to either be unaffordable to the employee or not provide the
required minimum actuarial value; and
(3) the Secretary of the Treasury makes advance payments of
such credit or reductions to the issuers of the qualified
health plans in order to reduce the premiums payable by
individuals eligible for such credit.
(b) Advance Determinations.--
(1) In general.--The Secretary shall provide under the
program established under subsection (a) that advance
determination of eligibility with respect to any individual
shall be made--
(A) during the annual open enrollment period applicable to
the individual (or such other enrollment period as may be
specified by the Secretary); and
(B) on the basis of the individual's household income for
the most recent taxable year for which the Secretary, after
consultation with the Secretary of the Treasury, determines
information is available.
(2) Changes in circumstances.--The Secretary shall provide
procedures for making advance determinations on the basis of
information other than that described in paragraph (1)(B) in
cases where information included with an application form
demonstrates substantial changes in income, changes in family
size or other household circumstances, change in filing
status, the filing of an application for unemployment
benefits, or other significant changes affecting eligibility,
including--
(A) allowing an individual claiming a decrease of 20
percent or more in income, or filing an application for
unemployment benefits, to have eligibility for the credit
determined on the basis of household income for a later
period or on the basis of the individual's estimate of such
income for the taxable year; and
(B) the determination of household income in cases where
the taxpayer was not required to file a return of tax imposed
by this chapter for the second preceding taxable year.
(c) Payment of Premium Tax Credits and Cost-sharing
Reductions.--
(1) In general.--The Secretary shall notify the Secretary
of the Treasury and the Exchange through which the individual
is enrolling of the advance determination under section 1411.
(2) Premium tax credit.--
(A) In general.--The Secretary of the Treasury shall make
the advance payment under this section of any premium tax
credit allowed under section 36B of the Internal Revenue Code
of 1986 to the issuer of a qualified health plan on a monthly
basis (or such other periodic basis as the Secretary may
provide).
(B) Issuer responsibilities.--An issuer of a qualified
health plan receiving an advance payment with respect to an
individual enrolled in the plan shall--
(i) reduce the premium charged the insured for any period
by the amount of the advance payment for the period;
(ii) notify the Exchange and the Secretary of such
reduction;
[[Page H1951]]
(iii) include with each billing statement the amount by
which the premium for the plan has been reduced by reason of
the advance payment; and
(iv) in the case of any nonpayment of premiums by the
insured--
(I) notify the Secretary of such nonpayment; and
(II) allow a 3-month grace period for nonpayment of
premiums before discontinuing coverage.
(3) Cost-sharing reductions.--The Secretary shall also
notify the Secretary of the Treasury and the Exchange under
paragraph (1) if an advance payment of the cost-sharing
reductions under section 1402 is to be made to the issuer of
any qualified health plan with respect to any individual
enrolled in the plan. The Secretary of the Treasury shall
make such advance payment at such time and in such amount as
the Secretary specifies in the notice.
(d) No Federal Payments for Individuals Not Lawfully
Present.--Nothing in this subtitle or the amendments made by
this subtitle allows Federal payments, credits, or cost-
sharing reductions for individuals who are not lawfully
present in the United States.
(e) State Flexibility.--Nothing in this subtitle or the
amendments made by this subtitle shall be construed to
prohibit a State from making payments to or on behalf of an
individual for coverage under a qualified health plan offered
through an Exchange that are in addition to any credits or
cost-sharing reductions allowable to the individual under
this subtitle and such amendments.
SEC. 1413. STREAMLINING OF PROCEDURES FOR ENROLLMENT THROUGH
AN EXCHANGE AND STATE MEDICAID, CHIP, AND
HEALTH SUBSIDY PROGRAMS.
(a) In General.--The Secretary shall establish a system
meeting the requirements of this section under which
residents of each State may apply for enrollment in, receive
a determination of eligibility for participation in, and
continue participation in, applicable State health subsidy
programs. Such system shall ensure that if an individual
applying to an Exchange is found through screening to be
eligible for medical assistance under the State medicaid plan
under title XIX, or eligible for enrollment under a State
children's health insurance program (CHIP) under title XXI of
such Act, the individual is enrolled for assistance under
such plan or program.
(b) Requirements Relating to Forms and Notice.--
(1) Requirements relating to forms.--
(A) In general.--The Secretary shall develop and provide to
each State a single, streamlined form that--
(i) may be used to apply for all applicable State health
subsidy programs within the State;
(ii) may be filed online, in person, by mail, or by
telephone;
(iii) may be filed with an Exchange or with State officials
operating one of the other applicable State health subsidy
programs; and
(iv) is structured to maximize an applicant's ability to
complete the form satisfactorily, taking into account the
characteristics of individuals who qualify for applicable
State health subsidy programs.
(B) State authority to establish form.--A State may develop
and use its own single, streamlined form as an alternative to
the form developed under subparagraph (A) if the alternative
form is consistent with standards promulgated by the
Secretary under this section.
(C) Supplemental eligibility forms.--The Secretary may
allow a State to use a supplemental or alternative form in
the case of individuals who apply for eligibility that is not
determined on the basis of the household income (as defined
in section 36B of the Internal Revenue Code of 1986).
(2) Notice.--The Secretary shall provide that an applicant
filing a form under paragraph (1) shall receive notice of
eligibility for an applicable State health subsidy program
without any need to provide additional information or
paperwork unless such information or paperwork is
specifically required by law when information provided on the
form is inconsistent with data used for the electronic
verification under paragraph (3) or is otherwise insufficient
to determine eligibility.
(c) Requirements Relating to Eligibility Based on Data
Exchanges.--
(1) Development of secure interfaces.--Each State shall
develop for all applicable State health subsidy programs a
secure, electronic interface allowing an exchange of data
(including information contained in the application forms
described in subsection (b)) that allows a determination of
eligibility for all such programs based on a single
application. Such interface shall be compatible with the
method established for data verification under section
1411(c)(4).
(2) Data matching program.--Each applicable State health
subsidy program shall participate in a data matching
arrangement for determining eligibility for participation in
the program under paragraph (3) that--
(A) provides access to data described in paragraph (3);
(B) applies only to individuals who--
(i) receive assistance from an applicable State health
subsidy program; or
(ii) apply for such assistance--
(I) by filing a form described in subsection (b); or
(II) by requesting a determination of eligibility and
authorizing disclosure of the information described in
paragraph (3) to applicable State health coverage subsidy
programs for purposes of determining and establishing
eligibility; and
(C) consistent with standards promulgated by the Secretary,
including the privacy and data security safeguards described
in section 1942 of the Social Security Act or that are
otherwise applicable to such programs.
(3) Determination of eligibility.--
(A) In general.--Each applicable State health subsidy
program shall, to the maximum extent practicable--
(i) establish, verify, and update eligibility for
participation in the program using the data matching
arrangement under paragraph (2); and
(ii) determine such eligibility on the basis of reliable,
third party data, including information described in sections
1137, 453(i), and 1942(a) of the Social Security Act,
obtained through such arrangement.
(B) Exception.--This paragraph shall not apply in
circumstances with respect to which the Secretary determines
that the administrative and other costs of use of the data
matching arrangement under paragraph (2) outweigh its
expected gains in accuracy, efficiency, and program
participation.
(4) Secretarial standards.--The Secretary shall, after
consultation with persons in possession of the data to be
matched and representatives of applicable State health
subsidy programs, promulgate standards governing the timing,
contents, and procedures for data matching described in this
subsection. Such standards shall take into account
administrative and other costs and the value of data matching
to the establishment, verification, and updating of
eligibility for applicable State health subsidy programs.
(d) Administrative Authority.--
(1) Agreements.--Subject to section 1411 and section
6103(l)(21) of the Internal Revenue Code of 1986 and any
other requirement providing safeguards of privacy and data
integrity, the Secretary may establish model agreements, and
enter into agreements, for the sharing of data under this
section.
(2) Authority of exchange to contract out.--Nothing in this
section shall be construed to--
(A) prohibit contractual arrangements through which a State
medicaid agency determines eligibility for all applicable
State health subsidy programs, but only if such agency
complies with the Secretary's requirements ensuring reduced
administrative costs, eligibility errors, and disruptions in
coverage; or
(B) change any requirement under title XIX that eligibility
for participation in a State's medicaid program must be
determined by a public agency.
(e) Applicable State Health Subsidy Program.--In this
section, the term ``applicable State health subsidy program''
means--
(1) the program under this title for the enrollment in
qualified health plans offered through an Exchange, including
the premium tax credits under section 36B of the Internal
Revenue Code of 1986 and cost-sharing reductions under
section 1402;
(2) a State medicaid program under title XIX of the Social
Security Act;
(3) a State children's health insurance program (CHIP)
under title XXI of such Act; and
(4) a State program under section 1331 establishing
qualified basic health plans.
SEC. 1414. DISCLOSURES TO CARRY OUT ELIGIBILITY REQUIREMENTS
FOR CERTAIN PROGRAMS.
(a) Disclosure of Taxpayer Return Information and Social
Security Numbers.--
(1) Taxpayer return information.--Subsection (l) of section
6103 of the Internal Revenue Code of 1986 is amended by
adding at the end the following new paragraph:
``(21) Disclosure of return information to carry out
eligibility requirements for certain programs.--
``(A) In general.--The Secretary, upon written request from
the Secretary of Health and Human Services, shall disclose to
officers, employees, and contractors of the Department of
Health and Human Services return information of any taxpayer
whose income is relevant in determining any premium tax
credit under section 36B or any cost-sharing reduction under
section 1402 of the Patient Protection and Affordable Care
Act or eligibility for participation in a State medicaid
program under title XIX of the Social Security Act, a State's
children's health insurance program under title XXI of the
Social Security Act, or a basic health program under section
1331 of Patient Protection and Affordable Care Act. Such
return information shall be limited to--
``(i) taxpayer identity information with respect to such
taxpayer,
``(ii) the filing status of such taxpayer,
``(iii) the number of individuals for whom a deduction is
allowed under section 151 with respect to the taxpayer
(including the taxpayer and the taxpayer's spouse),
``(iv) the modified gross income (as defined in section
36B) of such taxpayer and each of the other individuals
included under clause (iii) who are required to file a return
of tax imposed by chapter 1 for the taxable year,
``(v) such other information as is prescribed by the
Secretary by regulation as might indicate whether the
taxpayer is eligible for such credit or reduction (and the
amount thereof), and
``(vi) the taxable year with respect to which the preceding
information relates or, if applicable, the fact that such
information is not available.
``(B) Information to exchange and state agencies.--The
Secretary of Health and Human Services may disclose to an
Exchange established under the Patient Protection and
Affordable Care Act or its contractors, or to a State agency
administering a State program described in subparagraph (A)
or its contractors, any inconsistency between the information
provided by the Exchange or State agency to the Secretary and
the information provided to the Secretary under subparagraph
(A).
``(C) Restriction on use of disclosed information.--Return
information disclosed under subparagraph (A) or (B) may be
used by
[[Page H1952]]
officers, employees, and contractors of the Department of
Health and Human Services, an Exchange, or a State agency
only for the purposes of, and to the extent necessary in--
``(i) establishing eligibility for participation in the
Exchange, and verifying the appropriate amount of, any credit
or reduction described in subparagraph (A),
``(ii) determining eligibility for participation in the
State programs described in subparagraph (A).''.
(2) Social security numbers.--Section 205(c)(2)(C) of the
Social Security Act is amended by adding at the end the
following new clause:
``(x) The Secretary of Health and Human Services, and the
Exchanges established under section 1311 of the Patient
Protection and Affordable Care Act, are authorized to collect
and use the names and social security account numbers of
individuals as required to administer the provisions of, and
the amendments made by, the such Act.''.
(b) Confidentiality and Disclosure.--Paragraph (3) of
section 6103(a) of such Code is amended by striking ``or
(20)'' and inserting ``(20), or (21)''.
(c) Procedures and Recordkeeping Related to Disclosures.--
Paragraph (4) of section 6103(p) of such Code is amended--
(1) by inserting ``, or any entity described in subsection
(l)(21),'' after ``or (20)'' in the matter preceding
subparagraph (A),
(2) by inserting ``or any entity described in subsection
(l)(21),'' after ``or (o)(1)(A)'' in subparagraph (F)(ii),
and
(3) by inserting ``or any entity described in subsection
(l)(21),'' after ``or (20)'' both places it appears in the
matter after subparagraph (F).
(d) Unauthorized Disclosure or Inspection.--Paragraph (2)
of section 7213(a) of such Code is amended by striking ``or
(20)'' and inserting ``(20), or (21)''.
SEC. 1415. PREMIUM TAX CREDIT AND COST-SHARING REDUCTION
PAYMENTS DISREGARDED FOR FEDERAL AND FEDERALLY-
ASSISTED PROGRAMS.
For purposes of determining the eligibility of any
individual for benefits or assistance, or the amount or
extent of benefits or assistance, under any Federal program
or under any State or local program financed in whole or in
part with Federal funds--
(1) any credit or refund allowed or made to any individual
by reason of section 36B of the Internal Revenue Code of 1986
(as added by section 1401) shall not be taken into account as
income and shall not be taken into account as resources for
the month of receipt and the following 2 months; and
(2) any cost-sharing reduction payment or advance payment
of the credit allowed under such section 36B that is made
under section 1402 or 1412 shall be treated as made to the
qualified health plan in which an individual is enrolled and
not to that individual.
PART II--SMALL BUSINESS TAX CREDIT
SEC. 1421. CREDIT FOR EMPLOYEE HEALTH INSURANCE EXPENSES OF
SMALL BUSINESSES.
(a) In General.--Subpart D of part IV of subchapter A of
chapter 1 of the Internal Revenue Code of 1986 (relating to
business-related credits) is amended by inserting after
section 45Q the following:
``SEC. 45R. EMPLOYEE HEALTH INSURANCE EXPENSES OF SMALL
EMPLOYERS.
``(a) General Rule.--For purposes of section 38, in the
case of an eligible small employer, the small employer health
insurance credit determined under this section for any
taxable year in the credit period is the amount determined
under subsection (b).
``(b) Health Insurance Credit Amount.--Subject to
subsection (c), the amount determined under this subsection
with respect to any eligible small employer is equal to 50
percent (35 percent in the case of a tax-exempt eligible
small employer) of the lesser of--
``(1) the aggregate amount of nonelective contributions the
employer made on behalf of its employees during the taxable
year under the arrangement described in subsection (d)(4) for
premiums for qualified health plans offered by the employer
to its employees through an Exchange, or
``(2) the aggregate amount of nonelective contributions
which the employer would have made during the taxable year
under the arrangement if each employee taken into account
under paragraph (1) had enrolled in a qualified health plan
which had a premium equal to the average premium (as
determined by the Secretary of Health and Human Services) for
the small group market in the rating area in which the
employee enrolls for coverage.
``(c) Phaseout of Credit Amount Based on Number of
Employees and Average Wages.--The amount of the credit
determined under subsection (b) without regard to this
subsection shall be reduced (but not below zero) by the sum
of the following amounts:
``(1) Such amount multiplied by a fraction the numerator of
which is the total number of full-time equivalent employees
of the employer in excess of 10 and the denominator of which
is 15.
``(2) Such amount multiplied by a fraction the numerator of
which is the average annual wages of the employer in excess
of the dollar amount in effect under subsection (d)(3)(B) and
the denominator of which is such dollar amount.
``(d) Eligible Small Employer.--For purposes of this
section--
``(1) In general.--The term `eligible small employer'
means, with respect to any taxable year, an employer--
``(A) which has no more than 25 full-time equivalent
employees for the taxable year,
``(B) the average annual wages of which do not exceed an
amount equal to twice the dollar amount in effect under
paragraph (3)(B) for the taxable year, and
``(C) which has in effect an arrangement described in
paragraph (4).
``(2) Full-time equivalent employees.--
``(A) In general.--The term `full-time equivalent
employees' means a number of employees equal to the number
determined by dividing--
``(i) the total number of hours of service for which wages
were paid by the employer to employees during the taxable
year, by
``(ii) 2,080.
Such number shall be rounded to the next lowest whole number
if not otherwise a whole number.
``(B) Excess hours not counted.--If an employee works in
excess of 2,080 hours of service during any taxable year,
such excess shall not be taken into account under
subparagraph (A).
``(C) Hours of service.--The Secretary, in consultation
with the Secretary of Labor, shall prescribe such
regulations, rules, and guidance as may be necessary to
determine the hours of service of an employee, including
rules for the application of this paragraph to employees who
are not compensated on an hourly basis.
``(3) Average annual wages.--
``(A) In general.--The average annual wages of an eligible
small employer for any taxable year is the amount determined
by dividing--
``(i) the aggregate amount of wages which were paid by the
employer to employees during the taxable year, by
``(ii) the number of full-time equivalent employees of the
employee determined under paragraph (2) for the taxable year.
Such amount shall be rounded to the next lowest multiple of
$1,000 if not otherwise such a multiple.
``(B) Dollar amount.--For purposes of paragraph (1)(B)--
``(i) 2011, 2012, and 2013.--The dollar amount in effect
under this paragraph for taxable years beginning in 2011,
2012, or 2013 is $20,000.
``(ii) Subsequent years.--In the case of a taxable year
beginning in a calendar year after 2013, the dollar amount in
effect under this paragraph shall be equal to $20,000,
multiplied by the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year, determined by
substituting `calendar year 2012' for `calendar year 1992' in
subparagraph (B) thereof.
``(4) Contribution arrangement.--An arrangement is
described in this paragraph if it requires an eligible small
employer to make a nonelective contribution on behalf of each
employee who enrolls in a qualified health plan offered to
employees by the employer through an exchange in an amount
equal to a uniform percentage (not less than 50 percent) of
the premium cost of the qualified health plan.
``(5) Seasonal worker hours and wages not counted.--For
purposes of this subsection--
``(A) In general.--The number of hours of service worked
by, and wages paid to, a seasonal worker of an employer shall
not be taken into account in determining the full-time
equivalent employees and average annual wages of the employer
unless the worker works for the employer on more than 120
days during the taxable year.
``(B) Definition of seasonal worker.--The term `seasonal
worker' means a worker who performs labor or services on a
seasonal basis as defined by the Secretary of Labor,
including workers covered by section 500.20(s)(1) of title
29, Code of Federal Regulations and retail workers employed
exclusively during holiday seasons.
``(e) Other Rules and Definitions.--For purposes of this
section--
``(1) Employee.--
``(A) Certain employees excluded.--The term `employee'
shall not include--
``(i) an employee within the meaning of section 401(c)(1),
``(ii) any 2-percent shareholder (as defined in section
1372(b)) of an eligible small business which is an S
corporation,
``(iii) any 5-percent owner (as defined in section
416(i)(1)(B)(i)) of an eligible small business, or
``(iv) any individual who bears any of the relationships
described in subparagraphs (A) through (G) of section
152(d)(2) to, or is a dependent described in section
152(d)(2)(H) of, an individual described in clause (i), (ii),
or (iii).
``(B) Leased employees.--The term `employee' shall include
a leased employee within the meaning of section 414(n).
``(2) Credit period.--The term `credit period' means, with
respect to any eligible small employer, the 2-consecutive-
taxable year period beginning with the 1st taxable year in
which the employer (or any predecessor) offers 1 or more
qualified health plans to its employees through an Exchange.
``(3) Nonelective contribution.--The term `nonelective
contribution' means an employer contribution other than an
employer contribution pursuant to a salary reduction
arrangement.
``(4) Wages.--The term `wages' has the meaning given such
term by section 3121(a) (determined without regard to any
dollar limitation contained in such section).
``(5) Aggregation and other rules made applicable.--
``(A) Aggregation rules.--All employers treated as a single
employer under subsection (b), (c), (m), or (o) of section
414 shall be treated as a single employer for purposes of
this section.
``(B) Other rules.--Rules similar to the rules of
subsections (c), (d), and (e) of section 52 shall apply.
``(f) Credit Made Available to Tax-exempt Eligible Small
Employers.--
``(1) In general.--In the case of a tax-exempt eligible
small employer, there shall be treated as a credit allowable
under subpart C (and not allowable under this subpart) the
lesser of--
``(A) the amount of the credit determined under this
section with respect to such employer, or
[[Page H1953]]
``(B) the amount of the payroll taxes of the employer
during the calendar year in which the taxable year begins.
``(2) Tax-exempt eligible small employer.--For purposes of
this section, the term `tax-exempt eligible small employer'
means an eligible small employer which is any organization
described in section 501(c) which is exempt from taxation
under section 501(a).
``(3) Payroll taxes.--For purposes of this subsection--
``(A) In general.--The term `payroll taxes' means--
``(i) amounts required to be withheld from the employees of
the tax-exempt eligible small employer under section 3401(a),
``(ii) amounts required to be withheld from such employees
under section 3101(b), and
``(iii) amounts of the taxes imposed on the tax-exempt
eligible small employer under section 3111(b).
``(B) Special rule.--A rule similar to the rule of section
24(d)(2)(C) shall apply for purposes of subparagraph (A).
``(g) Application of Section for Calendar Years 2011, 2012,
and 2013.--In the case of any taxable year beginning in 2011,
2012, or 2013, the following modifications to this section
shall apply in determining the amount of the credit under
subsection (a):
``(1) No credit period required.--The credit shall be
determined without regard to whether the taxable year is in a
credit period and for purposes of applying this section to
taxable years beginning after 2013, no credit period shall be
treated as beginning with a taxable year beginning before
2014.
``(2) Amount of credit.--The amount of the credit
determined under subsection (b) shall be determined--
``(A) by substituting `35 percent (25 percent in the case
of a tax-exempt eligible small employer)' for `50 percent (35
percent in the case of a tax-exempt eligible small
employer)',
``(B) by reference to an eligible small employer's
nonelective contributions for premiums paid for health
insurance coverage (within the meaning of section 9832(b)(1))
of an employee, and
``(C) by substituting for the average premium determined
under subsection (b)(2) the amount the Secretary of Health
and Human Services determines is the average premium for the
small group market in the State in which the employer is
offering health insurance coverage (or for such area within
the State as is specified by the Secretary).
``(3) Contribution arrangement.--An arrangement shall not
fail to meet the requirements of subsection (d)(4) solely
because it provides for the offering of insurance outside of
an Exchange.
``(h) Insurance Definitions.--Any term used in this section
which is also used in the Public Health Service Act or
subtitle A of title I of the Patient Protection and
Affordable Care Act shall have the meaning given such term by
such Act or subtitle.
``(i) Regulations.--The Secretary shall prescribe such
regulations as may be necessary to carry out the provisions
of this section, including regulations to prevent the
avoidance of the 2-year limit on the credit period through
the use of successor entities and the avoidance of the
limitations under subsection (c) through the use of multiple
entities.''.
(b) Credit To Be Part of General Business Credit.--Section
38(b) of the Internal Revenue Code of 1986 (relating to
current year business credit) is amended by striking ``plus''
at the end of paragraph (34), by striking the period at the
end of paragraph (35) and inserting ``, plus'', and by
inserting after paragraph (35) the following:
``(36) the small employer health insurance credit
determined under section 45R.''.
(c) Credit Allowed Against Alternative Minimum Tax.--
Section 38(c)(4)(B) of the Internal Revenue Code of 1986
(defining specified credits) is amended by redesignating
clauses (vi), (vii), and (viii) as clauses (vii), (viii), and
(ix), respectively, and by inserting after clause (v) the
following new clause:
``(vi) the credit determined under section 45R,''.
(d) Disallowance of Deduction for Certain Expenses for
Which Credit Allowed.--
(1) In general.--Section 280C of the Internal Revenue Code
of 1986 (relating to disallowance of deduction for certain
expenses for which credit allowed), as amended by section
1401(b), is amended by adding at the end the following new
subsection:
``(h) Credit for Employee Health Insurance Expenses of
Small Employers.--No deduction shall be allowed for that
portion of the premiums for qualified health plans (as
defined in section 1301(a) of the Patient Protection and
Affordable Care Act), or for health insurance coverage in the
case of taxable years beginning in 2011, 2012, or 2013, paid
by an employer which is equal to the amount of the credit
determined under section 45R(a) with respect to the
premiums.''.
(2) Deduction for expiring credits.--Section 196(c) of such
Code is amended by striking ``and'' at the end of paragraph
(12), by striking the period at the end of paragraph (13) and
inserting ``, and'', and by adding at the end the following
new paragraph:
``(14) the small employer health insurance credit
determined under section 45R(a).''.
(e) Clerical Amendment.--The table of sections for subpart
D of part IV of subchapter A of chapter 1 of the Internal
Revenue Code of 1986 is amended by adding at the end the
following:
``Sec. 45R. Employee health insurance expenses of small employers.''.
(f) Effective Dates.--
(1) In general.--The amendments made by this section shall
apply to amounts paid or incurred in taxable years beginning
after December 31, 2010.
(2) Minimum tax.--The amendments made by subsection (c)
shall apply to credits determined under section 45R of the
Internal Revenue Code of 1986 in taxable years beginning
after December 31, 2010, and to carrybacks of such credits.
Subtitle F--Shared Responsibility for Health Care
PART I--INDIVIDUAL RESPONSIBILITY
SEC. 1501. REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL
COVERAGE.
(a) Findings.--Congress makes the following findings:
(1) In general.--The individual responsibility requirement
provided for in this section (in this subsection referred to
as the ``requirement'') is commercial and economic in nature,
and substantially affects interstate commerce, as a result of
the effects described in paragraph (2).
(2) Effects on the national economy and interstate
commerce.--The effects described in this paragraph are the
following:
(A) The requirement regulates activity that is commercial
and economic in nature: economic and financial decisions
about how and when health care is paid for, and when health
insurance is purchased.
(B) Health insurance and health care services are a
significant part of the national economy. National health
spending is projected to increase from $2,500,000,000,000, or
17.6 percent of the economy, in 2009 to $4,700,000,000,000 in
2019. Private health insurance spending is projected to be
$854,000,000,000 in 2009, and pays for medical supplies,
drugs, and equipment that are shipped in interstate commerce.
Since most health insurance is sold by national or regional
health insurance companies, health insurance is sold in
interstate commerce and claims payments flow through
interstate commerce.
(C) The requirement, together with the other provisions of
this Act, will add millions of new consumers to the health
insurance market, increasing the supply of, and demand for,
health care services. According to the Congressional Budget
Office, the requirement will increase the number and share of
Americans who are insured.
(D) The requirement achieves near-universal coverage by
building upon and strengthening the private employer-based
health insurance system, which covers 176,000,000 Americans
nationwide. In Massachusetts, a similar requirement has
strengthened private employer-based coverage: despite the
economic downturn, the number of workers offered employer-
based coverage has actually increased.
(E) Half of all personal bankruptcies are caused in part by
medical expenses. By significantly increasing health
insurance coverage, the requirement, together with the other
provisions of this Act, will improve financial security for
families.
(F) Under the Employee Retirement Income Security Act of
1974 (29 U.S.C. 1001 et seq.), the Public Health Service Act
(42 U.S.C. 201 et seq.), and this Act, the Federal Government
has a significant role in regulating health insurance which
is in interstate commerce.
(G) Under sections 2704 and 2705 of the Public Health
Service Act (as added by section 1201 of this Act), if there
were no requirement, many individuals would wait to purchase
health insurance until they needed care. By significantly
increasing health insurance coverage, the requirement,
together with the other provisions of this Act, will minimize
this adverse selection and broaden the health insurance risk
pool to include healthy individuals, which will lower health
insurance premiums. The requirement is essential to creating
effective health insurance markets in which improved health
insurance products that are guaranteed issue and do not
exclude coverage of pre-existing conditions can be sold.
(H) Administrative costs for private health insurance,
which were $90,000,000,000 in 2006, are 26 to 30 percent of
premiums in the current individual and small group markets.
By significantly increasing health insurance coverage and the
size of purchasing pools, which will increase economies of
scale, the requirement, together with the other provisions of
this Act, will significantly reduce administrative costs and
lower health insurance premiums. The requirement is essential
to creating effective health insurance markets that do not
require underwriting and eliminate its associated
administrative costs.
(3) Supreme court ruling.--In United States v. South-
Eastern Underwriters Association (322 U.S. 533 (1944)), the
Supreme Court of the United States ruled that insurance is
interstate commerce subject to Federal regulation.
(b) In General.--Subtitle D of the Internal Revenue Code of
1986 is amended by adding at the end the following new
chapter:
``CHAPTER 48--MAINTENANCE OF MINIMUM ESSENTIAL COVERAGE
``Sec. 5000A. Requirement to maintain minimum essential coverage.
``SEC. 5000A. REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL
COVERAGE.
``(a) Requirement To Maintain Minimum Essential Coverage.--
An applicable individual shall for each month beginning after
2013 ensure that the individual, and any dependent of the
individual who is an applicable individual, is covered under
minimum essential coverage for such month.
``(b) Shared Responsibility Payment.--
``(1) In general.--If an applicable individual fails to
meet the requirement of subsection (a) for 1 or more months
during any calendar year beginning after 2013, then, except
as provided in subsection (d), there is hereby imposed a
penalty with respect to the individual in the amount
determined under subsection (c).
``(2) Inclusion with return.--Any penalty imposed by this
section with respect to any
[[Page H1954]]
month shall be included with a taxpayer's return under
chapter 1 for the taxable year which includes such month.
``(3) Payment of penalty.--If an individual with respect to
whom a penalty is imposed by this section for any month--
``(A) is a dependent (as defined in section 152) of another
taxpayer for the other taxpayer's taxable year including such
month, such other taxpayer shall be liable for such penalty,
or
``(B) files a joint return for the taxable year including
such month, such individual and the spouse of such individual
shall be jointly liable for such penalty.
``(c) Amount of Penalty.--
``(1) In general.--The penalty determined under this
subsection for any month with respect to any individual is an
amount equal to \1/12\ of the applicable dollar amount for
the calendar year.
``(2) Dollar limitation.--The amount of the penalty imposed
by this section on any taxpayer for any taxable year with
respect to all individuals for whom the taxpayer is liable
under subsection (b)(3) shall not exceed an amount equal to
300 percent the applicable dollar amount (determined without
regard to paragraph (3)(C)) for the calendar year with or
within which the taxable year ends.
``(3) Applicable dollar amount.--For purposes of paragraph
(1)--
``(A) In general.--Except as provided in subparagraphs (B)
and (C), the applicable dollar amount is $750.
``(B) Phase in.--The applicable dollar amount is $95 for
2014 and $350 for 2015.
``(C) Special rule for individuals under age 18.--If an
applicable individual has not attained the age of 18 as of
the beginning of a month, the applicable dollar amount with
respect to such individual for the month shall be equal to
one-half of the applicable dollar amount for the calendar
year in which the month occurs.
``(D) Indexing of amount.--In the case of any calendar year
beginning after 2016, the applicable dollar amount shall be
equal to $750, increased by an amount equal to--
``(i) $750, multiplied by
``(ii) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year, determined by
substituting `calendar year 2015' for `calendar year 1992' in
subparagraph (B) thereof.
If the amount of any increase under clause (i) is not a
multiple of $50, such increase shall be rounded to the next
lowest multiple of $50.
``(4) Terms relating to income and families.--For purposes
of this section--
``(A) Family size.--The family size involved with respect
to any taxpayer shall be equal to the number of individuals
for whom the taxpayer is allowed a deduction under section
151 (relating to allowance of deduction for personal
exemptions) for the taxable year.
``(B) Household income.--The term `household income' means,
with respect to any taxpayer for any taxable year, an amount
equal to the sum of--
``(i) the modified gross income of the taxpayer, plus
``(ii) the aggregate modified gross incomes of all other
individuals who--
``(I) were taken into account in determining the taxpayer's
family size under paragraph (1), and
``(II) were required to file a return of tax imposed by
section 1 for the taxable year.
``(C) Modified gross income.--The term `modified gross
income' means gross income--
``(i) decreased by the amount of any deduction allowable
under paragraph (1), (3), (4), or (10) of section 62(a),
``(ii) increased by the amount of interest received or
accrued during the taxable year which is exempt from tax
imposed by this chapter, and
``(iii) determined without regard to sections 911, 931, and
933.
``(D) Poverty line.--
``(i) In general.--The term `poverty line' has the meaning
given that term in section 2110(c)(5) of the Social Security
Act (42 U.S.C. 1397jj(c)(5)).
``(ii) Poverty line used.--In the case of any taxable year
ending with or within a calendar year, the poverty line used
shall be the most recently published poverty line as of the
1st day of such calendar year.
``(d) Applicable Individual.--For purposes of this
section--
``(1) In general.--The term `applicable individual' means,
with respect to any month, an individual other than an
individual described in paragraph (2), (3), or (4).
``(2) Religious exemptions.--
``(A) Religious conscience exemption.--Such term shall not
include any individual for any month if such individual has
in effect an exemption under section 1311(d)(4)(H) of the
Patient Protection and Affordable Care Act which certifies
that such individual is a member of a recognized religious
sect or division thereof described in section 1402(g)(1) and
an adherent of established tenets or teachings of such sect
or division as described in such section.
``(B) Health care sharing ministry.--
``(i) In general.--Such term shall not include any
individual for any month if such individual is a member of a
health care sharing ministry for the month.
``(ii) Health care sharing ministry.--The term `health care
sharing ministry' means an organization--
``(I) which is described in section 501(c)(3) and is exempt
from taxation under section 501(a),
``(II) members of which share a common set of ethical or
religious beliefs and share medical expenses among members in
accordance with those beliefs and without regard to the State
in which a member resides or is employed,
``(III) members of which retain membership even after they
develop a medical condition,
``(IV) which (or a predecessor of which) has been in
existence at all times since December 31, 1999, and medical
expenses of its members have been shared continuously and
without interruption since at least December 31, 1999, and
``(V) which conducts an annual audit which is performed by
an independent certified public accounting firm in accordance
with generally accepted accounting principles and which is
made available to the public upon request.
``(3) Individuals not lawfully present.--Such term shall
not include an individual for any month if for the month the
individual is not a citizen or national of the United States
or an alien lawfully present in the United States.
``(4) Incarcerated individuals.--Such term shall not
include an individual for any month if for the month the
individual is incarcerated, other than incarceration pending
the disposition of charges.
``(e) Exemptions.--No penalty shall be imposed under
subsection (a) with respect to--
``(1) Individuals who cannot afford coverage.--
``(A) In general.--Any applicable individual for any month
if the applicable individual's required contribution
(determined on an annual basis) for coverage for the month
exceeds 8 percent of such individual's household income for
the taxable year described in section 1412(b)(1)(B) of the
Patient Protection and Affordable Care Act. For purposes of
applying this subparagraph, the taxpayer's household income
shall be increased by any exclusion from gross income for any
portion of the required contribution made through a salary
reduction arrangement.
``(B) Required contribution.--For purposes of this
paragraph, the term `required contribution' means--
``(i) in the case of an individual eligible to purchase
minimum essential coverage consisting of coverage through an
eligible-employer-sponsored plan, the portion of the annual
premium which would be paid by the individual (without regard
to whether paid through salary reduction or otherwise) for
self-only coverage, or
``(ii) in the case of an individual eligible only to
purchase minimum essential coverage described in subsection
(f)(1)(C), the annual premium for the lowest cost bronze plan
available in the individual market through the Exchange in
the State in the rating area in which the individual resides
(without regard to whether the individual purchased a
qualified health plan through the Exchange), reduced by the
amount of the credit allowable under section 36B for the
taxable year (determined as if the individual was covered by
a qualified health plan offered through the Exchange for the
entire taxable year).
``(C) Special rules for individuals related to employees.--
For purposes of subparagraph (B)(i), if an applicable
individual is eligible for minimum essential coverage through
an employer by reason of a relationship to an employee, the
determination shall be made by reference to the affordability
of the coverage to the employee.
``(D) Indexing.--In the case of plan years beginning in any
calendar year after 2014, subparagraph (A) shall be applied
by substituting for `8 percent' the percentage the Secretary
of Health and Human Services determines reflects the excess
of the rate of premium growth between the preceding calendar
year and 2013 over the rate of income growth for such period.
``(2) Taxpayers with income under 100 percent of poverty
line.--Any applicable individual for any month during a
calendar year if the individual's household income for the
taxable year described in section 1412(b)(1)(B) of the
Patient Protection and Affordable Care Act is less than 100
percent of the poverty line for the size of the family
involved (determined in the same manner as under subsection
(b)(4)).
``(3) Members of indian tribes.--Any applicable individual
for any month during which the individual is a member of an
Indian tribe (as defined in section 45A(c)(6)).
``(4) Months during short coverage gaps.--
``(A) In general.--Any month the last day of which occurred
during a period in which the applicable individual was not
covered by minimum essential coverage for a continuous period
of less than 3 months.
``(B) Special rules.--For purposes of applying this
paragraph--
``(i) the length of a continuous period shall be determined
without regard to the calendar years in which months in such
period occur,
``(ii) if a continuous period is greater than the period
allowed under subparagraph (A), no exception shall be
provided under this paragraph for any month in the period,
and
``(iii) if there is more than 1 continuous period described
in subparagraph (A) covering months in a calendar year, the
exception provided by this paragraph shall only apply to
months in the first of such periods.
The Secretary shall prescribe rules for the collection of the
penalty imposed by this section in cases where continuous
periods include months in more than 1 taxable year.
``(5) Hardships.--Any applicable individual who for any
month is determined by the Secretary of Health and Human
Services under section 1311(d)(4)(H) to have suffered a
hardship with respect to the capability to obtain coverage
under a qualified health plan.
``(f) Minimum Essential Coverage.--For purposes of this
section--
``(1) In general.--The term `minimum essential coverage'
means any of the following:
``(A) Government sponsored programs.--Coverage under--
``(i) the Medicare program under part A of title XVIII of
the Social Security Act,
``(ii) the Medicaid program under title XIX of the Social
Security Act,
``(iii) the CHIP program under title XXI of the Social
Security Act,
[[Page H1955]]
``(iv) the TRICARE for Life program,
``(v) the veteran's health care program under chapter 17 of
title 38, United States Code, or
``(vi) a health plan under section 2504(e) of title 22,
United States Code (relating to Peace Corps volunteers).
``(B) Employer-sponsored plan.--Coverage under an eligible
employer-sponsored plan.
``(C) Plans in the individual market.--Coverage under a
health plan offered in the individual market within a State.
``(D) Grandfathered health plan.--Coverage under a
grandfathered health plan.
``(E) Other coverage.--Such other health benefits coverage,
such as a State health benefits risk pool, as the Secretary
of Health and Human Services, in coordination with the
Secretary, recognizes for purposes of this subsection.
``(2) Eligible employer-sponsored plan.--The term `eligible
employer-sponsored plan' means, with respect to any employee,
a group health plan or group health insurance coverage
offered by an employer to the employee which is--
``(A) a governmental plan (within the meaning of section
2791(d)(8) of the Public Health Service Act), or
``(B) any other plan or coverage offered in the small or
large group market within a State.
Such term shall include a grandfathered health plan described
in paragraph (1)(D) offered in a group market.
``(3) Excepted benefits not treated as minimum essential
coverage.--The term `minimum essential coverage' shall not
include health insurance coverage which consists of coverage
of excepted benefits--
``(A) described in paragraph (1) of subsection (c) of
section 2791 of the Public Health Service Act; or
``(B) described in paragraph (2), (3), or (4) of such
subsection if the benefits are provided under a separate
policy, certificate, or contract of insurance.
``(4) Individuals residing outside united states or
residents of territories.--Any applicable individual shall be
treated as having minimum essential coverage for any month--
``(A) if such month occurs during any period described in
subparagraph (A) or (B) of section 911(d)(1) which is
applicable to the individual, or
``(B) if such individual is a bona fide resident of any
possession of the United States (as determined under section
937(a)) for such month.
``(5) Insurance-related terms.--Any term used in this
section which is also used in title I of the Patient
Protection and Affordable Care Act shall have the same
meaning as when used in such title.
``(g) Administration and Procedure.--
``(1) In general.--The penalty provided by this section
shall be paid upon notice and demand by the Secretary, and
except as provided in paragraph (2), shall be assessed and
collected in the same manner as an assessable penalty under
subchapter B of chapter 68.
``(2) Special rules.--Notwithstanding any other provision
of law--
``(A) Waiver of criminal penalties.--In the case of any
failure by a taxpayer to timely pay any penalty imposed by
this section, such taxpayer shall not be subject to any
criminal prosecution or penalty with respect to such failure.
``(B) Limitations on liens and levies.--The Secretary shall
not--
``(i) file notice of lien with respect to any property of a
taxpayer by reason of any failure to pay the penalty imposed
by this section, or
``(ii) levy on any such property with respect to such
failure.''.
(c) Clerical Amendment.--The table of chapters for subtitle
D of the Internal Revenue Code of 1986 is amended by
inserting after the item relating to chapter 47 the following
new item:
``Chapter 48--Maintenance of Minimum Essential Coverage.''.
(d) Effective Date.--The amendments made by this section
shall apply to taxable years ending after December 31, 2013.
SEC. 1502. REPORTING OF HEALTH INSURANCE COVERAGE.
(a) In General.--Part III of subchapter A of chapter 61 of
the Internal Revenue Code of 1986 is amended by inserting
after subpart C the following new subpart:
``Subpart D--Information Regarding Health Insurance Coverage
``Sec. 6055. Reporting of health insurance coverage.
``SEC. 6055. REPORTING OF HEALTH INSURANCE COVERAGE.
``(a) In General.--Every person who provides minimum
essential coverage to an individual during a calendar year
shall, at such time as the Secretary may prescribe, make a
return described in subsection (b).
``(b) Form and Manner of Return.--
``(1) In general.--A return is described in this subsection
if such return--
``(A) is in such form as the Secretary may prescribe, and
``(B) contains--
``(i) the name, address and TIN of the primary insured and
the name and TIN of each other individual obtaining coverage
under the policy,
``(ii) the dates during which such individual was covered
under minimum essential coverage during the calendar year,
``(iii) in the case of minimum essential coverage which
consists of health insurance coverage, information
concerning--
``(I) whether or not the coverage is a qualified health
plan offered through an Exchange established under section
1311 of the Patient Protection and Affordable Care Act, and
``(II) in the case of a qualified health plan, the amount
(if any) of any advance payment under section 1412 of the
Patient Protection and Affordable Care Act of any cost-
sharing reduction under section 1402 of such Act or of any
premium tax credit under section 36B with respect to such
coverage, and
``(iv) such other information as the Secretary may require.
``(2) Information relating to employer-provided coverage.--
If minimum essential coverage provided to an individual under
subsection (a) consists of health insurance coverage of a
health insurance issuer provided through a group health plan
of an employer, a return described in this subsection shall
include--
``(A) the name, address, and employer identification number
of the employer maintaining the plan,
``(B) the portion of the premium (if any) required to be
paid by the employer, and
``(C) if the health insurance coverage is a qualified
health plan in the small group market offered through an
Exchange, such other information as the Secretary may require
for administration of the credit under section 45R (relating
to credit for employee health insurance expenses of small
employers).
``(c) Statements To Be Furnished to Individuals With
Respect to Whom Information Is Reported.--
``(1) In general.--Every person required to make a return
under subsection (a) shall furnish to each individual whose
name is required to be set forth in such return a written
statement showing--
``(A) the name and address of the person required to make
such return and the phone number of the information contact
for such person, and
``(B) the information required to be shown on the return
with respect to such individual.
``(2) Time for furnishing statements.--The written
statement required under paragraph (1) shall be furnished on
or before January 31 of the year following the calendar year
for which the return under subsection (a) was required to be
made.
``(d) Coverage Provided by Governmental Units.--In the case
of coverage provided by any governmental unit or any agency
or instrumentality thereof, the officer or employee who
enters into the agreement to provide such coverage (or the
person appropriately designated for purposes of this section)
shall make the returns and statements required by this
section.
``(e) Minimum Essential Coverage.--For purposes of this
section, the term `minimum essential coverage' has the
meaning given such term by section 5000A(f).''.
(b) Assessable Penalties.--
(1) Subparagraph (B) of section 6724(d)(1) of the Internal
Revenue Code of 1986 (relating to definitions) is amended by
striking ``or'' at the end of clause (xxii), by striking
``and'' at the end of clause (xxiii) and inserting ``or'',
and by inserting after clause (xxiii) the following new
clause:
``(xxiv) section 6055 (relating to returns relating to
information regarding health insurance coverage), and''.
(2) Paragraph (2) of section 6724(d) of such Code is
amended by striking ``or'' at the end of subparagraph (EE),
by striking the period at the end of subparagraph (FF) and
inserting ``, or'' and by inserting after subparagraph (FF)
the following new subparagraph:
``(GG) section 6055(c) (relating to statements relating to
information regarding health insurance coverage).''.
(c) Notification of Nonenrollment.--Not later than June 30
of each year, the Secretary of the Treasury, acting through
the Internal Revenue Service and in consultation with the
Secretary of Health and Human Services, shall send a
notification to each individual who files an individual
income tax return and who is not enrolled in minimum
essential coverage (as defined in section 5000A of the
Internal Revenue Code of 1986). Such notification shall
contain information on the services available through the
Exchange operating in the State in which such individual
resides.
(d) Conforming Amendment.--The table of subparts for part
III of subchapter A of chapter 61 of such Code is amended by
inserting after the item relating to subpart C the following
new item:
``subpart d--information regarding health insurance coverage''.
(e) Effective Date.--The amendments made by this section
shall apply to calendar years beginning after 2013.
PART II--EMPLOYER RESPONSIBILITIES
SEC. 1511. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF LARGE
EMPLOYERS.
The Fair Labor Standards Act of 1938 is amended by
inserting after section 18 (29 U.S.C. 218) the following:
``SEC. 18A. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF LARGE
EMPLOYERS.
``In accordance with regulations promulgated by the
Secretary, an employer to which this Act applies that has
more than 200 full-time employees and that offers employees
enrollment in 1 or more health benefits plans shall
automatically enroll new full-time employees in one of the
plans offered (subject to any waiting period authorized by
law) and to continue the enrollment of current employees in a
health benefits plan offered through the employer. Any
automatic enrollment program shall include adequate notice
and the opportunity for an employee to opt out of any
coverage the individual or employee were automatically
enrolled in. Nothing in this section shall be construed to
supersede any State law which establishes, implements, or
continues in effect any standard or requirement relating to
employers in connection with payroll except to the extent
that such standard or requirement prevents an employer from
instituting
[[Page H1956]]
the automatic enrollment program under this section.''.
SEC. 1512. EMPLOYER REQUIREMENT TO INFORM EMPLOYEES OF
COVERAGE OPTIONS.
The Fair Labor Standards Act of 1938 is amended by
inserting after section 18A (as added by section 1513) the
following:
``SEC. 18B. NOTICE TO EMPLOYEES.
``(a) In General.--In accordance with regulations
promulgated by the Secretary, an employer to which this Act
applies, shall provide to each employee at the time of hiring
(or with respect to current employees, not later than March
1, 2013), written notice--
``(1) informing the employee of the existence of an
Exchange, including a description of the services provided by
such Exchange, and the manner in which the employee may
contact the Exchange to request assistance;
``(2) if the employer plan's share of the total allowed
costs of benefits provided under the plan is less than 60
percent of such costs, that the employee may be eligible for
a premium tax credit under section 36B of the Internal
Revenue Code of 1986 and a cost sharing reduction under
section 1402 of the Patient Protection and Affordable Care
Act if the employee purchases a qualified health plan through
the Exchange; and
``(3) if the employee purchases a qualified health plan
through the Exchange, the employee will lose the employer
contribution (if any) to any health benefits plan offered by
the employer and that all or a portion of such contribution
may be excludable from income for Federal income tax
purposes.
``(b) Effective Date.--Subsection (a) shall take effect
with respect to employers in a State beginning on March 1,
2013.''.
SEC. 1513. SHARED RESPONSIBILITY FOR EMPLOYERS.
(a) In General.--Chapter 43 of the Internal Revenue Code of
1986 is amended by adding at the end the following:
``SEC. 4980H. SHARED RESPONSIBILITY FOR EMPLOYERS REGARDING
HEALTH COVERAGE.
``(a) Large Employers Not Offering Health Coverage.--If--
``(1) any applicable large employer fails to offer to its
full-time employees (and their dependents) the opportunity to
enroll in minimum essential coverage under an eligible
employer-sponsored plan (as defined in section 5000A(f)(2))
for any month, and
``(2) at least one full-time employee of the applicable
large employer has been certified to the employer under
section 1411 of the Patient Protection and Affordable Care
Act as having enrolled for such month in a qualified health
plan with respect to which an applicable premium tax credit
or cost-sharing reduction is allowed or paid with respect to
the employee,
then there is hereby imposed on the employer an assessable
payment equal to the product of the applicable payment amount
and the number of individuals employed by the employer as
full-time employees during such month.
``(b) Large Employers With Waiting Periods Exceeding 30
Days.--
``(1) In general.--In the case of any applicable large
employer which requires an extended waiting period to enroll
in any minimum essential coverage under an employer-sponsored
plan (as defined in section 5000A(f)(2)), there is hereby
imposed on the employer an assessable payment, in the amount
specified in paragraph (2), for each full-time employee of
the employer to whom the extended waiting period applies.
``(2) Amount.--For purposes of paragraph (1), the amount
specified in this paragraph for a full-time employee is--
``(A) in the case of an extended waiting period which
exceeds 30 days but does not exceed 60 days, $400, and
``(B) in the case of an extended waiting period which
exceeds 60 days, $600.
``(3) Extended waiting period.--The term `extended waiting
period' means any waiting period (as defined in section
2701(b)(4) of the Public Health Service Act) which exceeds 30
days.
``(c) Large Employers Offering Coverage With Employees Who
Qualify for Premium Tax Credits or Cost-sharing Reductions.--
``(1) In general.--If--
``(A) an applicable large employer offers to its full-time
employees (and their dependents) the opportunity to enroll in
minimum essential coverage under an eligible employer-
sponsored plan (as defined in section 5000A(f)(2)) for any
month, and
``(B) 1 or more full-time employees of the applicable large
employer has been certified to the employer under section
1411 of the Patient Protection and Affordable Care Act as
having enrolled for such month in a qualified health plan
with respect to which an applicable premium tax credit or
cost-sharing reduction is allowed or paid with respect to the
employee,
then there is hereby imposed on the employer an assessable
payment equal to the product of the number of full-time
employees of the applicable large employer described in
subparagraph (B) for such month and 400 percent of the
applicable payment amount.
``(2) Overall limitation.--The aggregate amount of tax
determined under paragraph (1) with respect to all employees
of an applicable large employer for any month shall not
exceed the product of the applicable payment amount and the
number of individuals employed by the employer as full-time
employees during such month.
``(d) Definitions and Special Rules.--For purposes of this
section--
``(1) Applicable payment amount.--The term `applicable
payment amount' means, with respect to any month, \1/12\ of
$750.
``(2) Applicable large employer.--
``(A) In general.--The term `applicable large employer'
means, with respect to a calendar year, an employer who
employed an average of at least 50 full-time employees on
business days during the preceding calendar year.
``(B) Exemption for certain employers.--
``(i) In general.--An employer shall not be considered to
employ more than 50 full-time employees if--
``(I) the employer's workforce exceeds 50 full-time
employees for 120 days or fewer during the calendar year, and
``(II) the employees in excess of 50 employed during such
120-day period were seasonal workers.
``(ii) Definition of seasonal workers.--The term `seasonal
worker' means a worker who performs labor or services on a
seasonal basis as defined by the Secretary of Labor,
including workers covered by section 500.20(s)(1) of title
29, Code of Federal Regulations and retail workers employed
exclusively during holiday seasons.
``(C) Rules for determining employer size.--For purposes of
this paragraph--
``(i) Application of aggregation rule for employers.--All
persons treated as a single employer under subsection (b),
(c), (m), or (o) of section 414 of the Internal Revenue Code
of 1986 shall be treated as 1 employer.
``(ii) Employers not in existence in preceding year.--In
the case of an employer which was not in existence throughout
the preceding calendar year, the determination of whether
such employer is an applicable large employer shall be based
on the average number of employees that it is reasonably
expected such employer will employ on business days in the
current calendar year.
``(iii) Predecessors.--Any reference in this subsection to
an employer shall include a reference to any predecessor of
such employer.
``(3) Applicable premium tax credit and cost-sharing
reduction.--The term `applicable premium tax credit and cost-
sharing reduction' means--
``(A) any premium tax credit allowed under section 36B,
``(B) any cost-sharing reduction under section 1402 of the
Patient Protection and Affordable Care Act, and
``(C) any advance payment of such credit or reduction under
section 1412 of such Act.
``(4) Full-time employee.--
``(A) In general.--The term `full-time employee' means an
employee who is employed on average at least 30 hours of
service per week.
``(B) Hours of service.--The Secretary, in consultation
with the Secretary of Labor, shall prescribe such
regulations, rules, and guidance as may be necessary to
determine the hours of service of an employee, including
rules for the application of this paragraph to employees who
are not compensated on an hourly basis.
``(5) Inflation adjustment.--
``(A) In general.--In the case of any calendar year after
2014, each of the dollar amounts in subsection (b)(2) and
(d)(1) shall be increased by an amount equal to the product
of--
``(i) such dollar amount, and
``(ii) the premium adjustment percentage (as defined in
section 1302(c)(4) of the Patient Protection and Affordable
Care Act) for the calendar year.
``(B) Rounding.--If the amount of any increase under
subparagraph (A) is not a multiple of $10, such increase
shall be rounded to the next lowest multiple of $10.
``(6) Other definitions.--Any term used in this section
which is also used in the Patient Protection and Affordable
Care Act shall have the same meaning as when used in such
Act.
``(7) Tax nondeductible.--For denial of deduction for the
tax imposed by this section, see section 275(a)(6).
``(e) Administration and Procedure.--
``(1) In general.--Any assessable payment provided by this
section shall be paid upon notice and demand by the
Secretary, and shall be assessed and collected in the same
manner as an assessable penalty under subchapter B of chapter
68.
``(2) Time for payment.--The Secretary may provide for the
payment of any assessable payment provided by this section on
an annual, monthly, or other periodic basis as the Secretary
may prescribe.
``(3) Coordination with credits, etc..--The Secretary shall
prescribe rules, regulations, or guidance for the repayment
of any assessable payment (including interest) if such
payment is based on the allowance or payment of an applicable
premium tax credit or cost-sharing reduction with respect to
an employee, such allowance or payment is subsequently
disallowed, and the assessable payment would not have been
required to be made but for such allowance or payment.''.
(b) Clerical Amendment.--The table of sections for chapter
43 of such Code is amended by adding at the end the following
new item:
``Sec. 4980H. Shared responsibility for employers regarding health
coverage.''.
(c) Study and Report of Effect of Tax on Workers' Wages.--
(1) In general.--The Secretary of Labor shall conduct a
study to determine whether employees' wages are reduced by
reason of the application of the assessable payments under
section 4980H of the Internal Revenue Code of 1986 (as added
by the amendments made by this section). The Secretary shall
make such determination on the basis of the National
Compensation Survey published by the Bureau of Labor
Statistics.
(2) Report.--The Secretary shall report the results of the
study under paragraph (1) to the Committee on Ways and Means
of the House of Representatives and to the Committee on
Finance of the Senate.
(d) Effective Date.--The amendments made by this section
shall apply to months beginning after December 31, 2013.
[[Page H1957]]
SEC. 1514. REPORTING OF EMPLOYER HEALTH INSURANCE COVERAGE.
(a) In General.--Subpart D of part III of subchapter A of
chapter 61 of the Internal Revenue Code of 1986, as added by
section 1502, is amended by inserting after section 6055 the
following new section:
``SEC. 6056. LARGE EMPLOYERS REQUIRED TO REPORT ON HEALTH
INSURANCE COVERAGE.
``(a) In General.--Every applicable large employer required
to meet the requirements of section 4980H with respect to its
full-time employees during a calendar year shall, at such
time as the Secretary may prescribe, make a return described
in subsection (b).
``(b) Form and Manner of Return.--A return is described in
this subsection if such return--
``(1) is in such form as the Secretary may prescribe, and
``(2) contains--
``(A) the name, date, and employer identification number of
the employer,
``(B) a certification as to whether the employer offers to
its full-time employees (and their dependents) the
opportunity to enroll in minimum essential coverage under an
eligible employer-sponsored plan (as defined in section
5000A(f)(2)),
``(C) if the employer certifies that the employer did offer
to its full-time employees (and their dependents) the
opportunity to so enroll--
``(i) the length of any waiting period (as defined in
section 2701(b)(4) of the Public Health Service Act) with
respect to such coverage,
``(ii) the months during the calendar year for which
coverage under the plan was available,
``(iii) the monthly premium for the lowest cost option in
each of the enrollment categories under the plan, and
``(iv) the applicable large employer's share of the total
allowed costs of benefits provided under the plan,
``(D) the number of full-time employees for each month
during the calendar year,
``(E) the name, address, and TIN of each full-time employee
during the calendar year and the months (if any) during which
such employee (and any dependents) were covered under any
such health benefits plans, and
``(F) such other information as the Secretary may require.
``(c) Statements To Be Furnished to Individuals With
Respect to Whom Information Is Reported.--
``(1) In general.--Every person required to make a return
under subsection (a) shall furnish to each full-time employee
whose name is required to be set forth in such return under
subsection (b)(2)(E) a written statement showing--
``(A) the name and address of the person required to make
such return and the phone number of the information contact
for such person, and
``(B) the information required to be shown on the return
with respect to such individual.
``(2) Time for furnishing statements.--The written
statement required under paragraph (1) shall be furnished on
or before January 31 of the year following the calendar year
for which the return under subsection (a) was required to be
made.
``(d) Coordination With Other Requirements.--To the maximum
extent feasible, the Secretary may provide that--
``(1) any return or statement required to be provided under
this section may be provided as part of any return or
statement required under section 6051 or 6055, and
``(2) in the case of an applicable large employer offering
health insurance coverage of a health insurance issuer, the
employer may enter into an agreement with the issuer to
include information required under this section with the
return and statement required to be provided by the issuer
under section 6055.
``(e) Coverage Provided by Governmental Units.--In the case
of any applicable large employer which is a governmental unit
or any agency or instrumentality thereof, the person
appropriately designated for purposes of this section shall
make the returns and statements required by this section.
``(f) Definitions.--For purposes of this section, any term
used in this section which is also used in section 4980H
shall have the meaning given such term by section 4980H.''.
(b) Assessable Penalties.--
(1) Subparagraph (B) of section 6724(d)(1) of the Internal
Revenue Code of 1986 (relating to definitions), as amended by
section 1502, is amended by striking ``or'' at the end of
clause (xxiii), by striking ``and'' at the end of clause
(xxiv) and inserting ``or'', and by inserting after clause
(xxiv) the following new clause:
``(xxv) section 6056 (relating to returns relating to large
employers required to report on health insurance coverage),
and''.
(2) Paragraph (2) of section 6724(d) of such Code, as so
amended, is amended by striking ``or'' at the end of
subparagraph (FF), by striking the period at the end of
subparagraph (GG) and inserting ``, or'' and by inserting
after subparagraph (GG) the following new subparagraph:
``(HH) section 6056(c) (relating to statements relating to
large employers required to report on health insurance
coverage).''.
(c) Conforming Amendment.--The table of sections for
subpart D of part III of subchapter A of chapter 61 of such
Code, as added by section 1502, is amended by adding at the
end the following new item:
``Sec. 6056. Large employers required to report on health insurance
coverage.''.
(d) Effective Date.--The amendments made by this section
shall apply to periods beginning after December 31, 2013.
SEC. 1515. OFFERING OF EXCHANGE-PARTICIPATING QUALIFIED
HEALTH PLANS THROUGH CAFETERIA PLANS.
(a) In General.--Subsection (f) of section 125 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new paragraph:
``(3) Certain exchange-participating qualified health plans
not qualified.--
``(A) In general.--The term `qualified benefit' shall not
include any qualified health plan (as defined in section
1301(a) of the Patient Protection and Affordable Care Act)
offered through an Exchange established under section 1311 of
such Act.
``(B) Exception for exchange-eligible employers.--
Subparagraph (A) shall not apply with respect to any employee
if such employee's employer is a qualified employer (as
defined in section 1312(f)(2) of the Patient Protection and
Affordable Care Act) offering the employee the opportunity to
enroll through such an Exchange in a qualified health plan in
a group market.''.
(b) Conforming Amendments.--Subsection (f) of section 125
of such Code is amended--
(1) by striking ``For purposes of this section, the term''
and inserting ``For purposes of this section--
``(1) In General.--The term'', and
(2) by striking ``Such term shall not include'' and
inserting the following:
``(2) Long-term care insurance not qualified.--The term
`qualified benefit' shall not include''.
(c) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2013.
Subtitle G--Miscellaneous Provisions
SEC. 1551. DEFINITIONS.
Unless specifically provided for otherwise, the definitions
contained in section 2791 of the Public Health Service Act
(42 U.S.C. 300gg-91) shall apply with respect to this title.
SEC. 1552. TRANSPARENCY IN GOVERNMENT.
Not later than 30 days after the date of enactment of this
Act, the Secretary of Health and Human Services shall publish
on the Internet website of the Department of Health and Human
Services, a list of all of the authorities provided to the
Secretary under this Act (and the amendments made by this
Act).
SEC. 1553. PROHIBITION AGAINST DISCRIMINATION ON ASSISTED
SUICIDE.
(a) In General.--The Federal Government, and any State or
local government or health care provider that receives
Federal financial assistance under this Act (or under an
amendment made by this Act) or any health plan created under
this Act (or under an amendment made by this Act), may not
subject an individual or institutional health care entity to
discrimination on the basis that the entity does not provide
any health care item or service furnished for the purpose of
causing, or for the purpose of assisting in causing, the
death of any individual, such as by assisted suicide,
euthanasia, or mercy killing.
(b) Definition.--In this section, the term ``health care
entity'' includes an individual physician or other health
care professional, a hospital, a provider-sponsored
organization, a health maintenance organization, a health
insurance plan, or any other kind of health care facility,
organization, or plan.
(c) Construction and Treatment of Certain Services.--
Nothing in subsection (a) shall be construed to apply to, or
to affect, any limitation relating to--
(1) the withholding or withdrawing of medical treatment or
medical care;
(2) the withholding or withdrawing of nutrition or
hydration;
(3) abortion; or
(4) the use of an item, good, benefit, or service furnished
for the purpose of alleviating pain or discomfort, even if
such use may increase the risk of death, so long as such
item, good, benefit, or service is not also furnished for the
purpose of causing, or the purpose of assisting in causing,
death, for any reason.
(d) Administration.--The Office for Civil Rights of the
Department of Health and Human Services is designated to
receive complaints of discrimination based on this section.
SEC. 1554. ACCESS TO THERAPIES.
Notwithstanding any other provision of this Act, the
Secretary of Health and Human Services shall not promulgate
any regulation that--
(1) creates any unreasonable barriers to the ability of
individuals to obtain appropriate medical care;
(2) impedes timely access to health care services;
(3) interferes with communications regarding a full range
of treatment options between the patient and the provider;
(4) restricts the ability of health care providers to
provide full disclosure of all relevant information to
patients making health care decisions;
(5) violates the principles of informed consent and the
ethical standards of health care professionals; or
(6) limits the availability of health care treatment for
the full duration of a patient's medical needs.
SEC. 1555. FREEDOM NOT TO PARTICIPATE IN FEDERAL HEALTH
INSURANCE PROGRAMS.
No individual, company, business, nonprofit entity, or
health insurance issuer offering group or individual health
insurance coverage shall be required to participate in any
Federal health insurance program created under this Act (or
any amendments made by this Act), or in any Federal health
insurance program expanded by this Act (or any such
amendments), and there shall be no penalty or fine imposed
upon any such issuer for choosing not to participate in such
programs.
SEC. 1556. EQUITY FOR CERTAIN ELIGIBLE SURVIVORS.
(a) Rebuttable Presumption.--Section 411(c)(4) of the Black
Lung Benefits Act (30
[[Page H1958]]
U.S.C. 921(c)(4)) is amended by striking the last sentence.
(b) Continuation of Benefits.--Section 422(l) of the Black
Lung Benefits Act (30 U.S.C. 932(l)) is amended by striking
``, except with respect to a claim filed under this part on
or after the effective date of the Black Lung Benefits
Amendments of 1981''.
(c) Effective Date.--The amendments made by this section
shall apply with respect to claims filed under part B or part
C of the Black Lung Benefits Act (30 U.S.C. 921 et seq., 931
et seq.) after January 1, 2005, that are pending on or after
the date of enactment of this Act.
SEC. 1557. NONDISCRIMINATION.
(a) In General.--Except as otherwise provided for in this
title (or an amendment made by this title), an individual
shall not, on the ground prohibited under title VI of the
Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), title IX
of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.),
the Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.),
or section 504 of the Rehabilitation Act of 1973 (29 U.S.C.
794), be excluded from participation in, be denied the
benefits of, or be subjected to discrimination under, any
health program or activity, any part of which is receiving
Federal financial assistance, including credits, subsidies,
or contracts of insurance, or under any program or activity
that is administered by an Executive Agency or any entity
established under this title (or amendments). The enforcement
mechanisms provided for and available under such title VI,
title IX, section 504, or such Age Discrimination Act shall
apply for purposes of violations of this subsection.
(b) Continued Application of Laws.--Nothing in this title
(or an amendment made by this title) shall be construed to
invalidate or limit the rights, remedies, procedures, or
legal standards available to individuals aggrieved under
title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et
seq.), title VII of the Civil Rights Act of 1964 (42 U.S.C.
2000e et seq.), title IX of the Education Amendments of 1972
(20 U.S.C. 1681 et seq.), section 504 of the Rehabilitation
Act of 1973 (29 U.S.C. 794), or the Age Discrimination Act of
1975 (42 U.S.C. 611 et seq.), or to supersede State laws that
provide additional protections against discrimination on any
basis described in subsection (a).
(c) Regulations.--The Secretary may promulgate regulations
to implement this section.
SEC. 1558. PROTECTIONS FOR EMPLOYEES.
The Fair Labor Standards Act of 1938 is amended by
inserting after section 18B (as added by section 1512) the
following:
``SEC. 18C. PROTECTIONS FOR EMPLOYEES.
``(a) Prohibition.--No employer shall discharge or in any
manner discriminate against any employee with respect to his
or her compensation, terms, conditions, or other privileges
of employment because the employee (or an individual acting
at the request of the employee) has--
``(1) received a credit under section 36B of the Internal
Revenue Code of 1986 or a subsidy under section 1402 of this
Act;
``(2) provided, caused to be provided, or is about to
provide or cause to be provided to the employer, the Federal
Government, or the attorney general of a State information
relating to any violation of, or any act or omission the
employee reasonably believes to be a violation of, any
provision of this title (or an amendment made by this title);
``(3) testified or is about to testify in a proceeding
concerning such violation;
``(4) assisted or participated, or is about to assist or
participate, in such a proceeding; or
``(5) objected to, or refused to participate in, any
activity, policy, practice, or assigned task that the
employee (or other such person) reasonably believed to be in
violation of any provision of this title (or amendment), or
any order, rule, regulation, standard, or ban under this
title (or amendment).
``(b) Complaint Procedure.--
``(1) In general.--An employee who believes that he or she
has been discharged or otherwise discriminated against by any
employer in violation of this section may seek relief in
accordance with the procedures, notifications, burdens of
proof, remedies, and statutes of limitation set forth in
section 2087(b) of title 15, United States Code.
``(2) No limitation on rights.--Nothing in this section
shall be deemed to diminish the rights, privileges, or
remedies of any employee under any Federal or State law or
under any collective bargaining agreement. The rights and
remedies in this section may not be waived by any agreement,
policy, form, or condition of employment.''.
SEC. 1559. OVERSIGHT.
The Inspector General of the Department of Health and Human
Services shall have oversight authority with respect to the
administration and implementation of this title as it relates
to such Department.
SEC. 1560. RULES OF CONSTRUCTION.
(a) No Effect on Antitrust Laws.--Nothing in this title (or
an amendment made by this title) shall be construed to
modify, impair, or supersede the operation of any of the
antitrust laws. For the purposes of this section, the term
``antitrust laws'' has the meaning given such term in
subsection (a) of the first section of the Clayton Act,
except that such term includes section 5 of the Federal Trade
Commission Act to the extent that such section 5 applies to
unfair methods of competition.
(b) Rule of Construction Regarding Hawaii's Prepaid Health
Care Act.--Nothing in this title (or an amendment made by
this title) shall be construed to modify or limit the
application of the exemption for Hawaii's Prepaid Health Care
Act (Haw. Rev. Stat. Sec. Sec. 393-1 et seq.) as provided
for under section 514(b)(5) of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1144(b)(5)).
(c) Student Health Insurance Plans.--Nothing in this title
(or an amendment made by this title) shall be construed to
prohibit an institution of higher education (as such term is
defined for purposes of the Higher Education Act of 1965)
from offering a student health insurance plan, to the extent
that such requirement is otherwise permitted under applicable
Federal, State or local law.
(d) No Effect on Existing Requirements.--Nothing in this
title (or an amendment made by this title, unless specified
by direct statutory reference) shall be construed to modify
any existing Federal requirement concerning the State agency
responsible for determining eligibility for programs
identified in section 1413.
SEC. 1561. HEALTH INFORMATION TECHNOLOGY ENROLLMENT STANDARDS
AND PROTOCOLS.
Title XXX of the Public Health Service Act (42 U.S.C. 300jj
et seq.) is amended by adding at the end the following:
``Subtitle C--Other Provisions
``SEC. 3021. HEALTH INFORMATION TECHNOLOGY ENROLLMENT
STANDARDS AND PROTOCOLS.
``(a) In General.--
``(1) Standards and protocols.--Not later than 180 days
after the date of enactment of this title, the Secretary, in
consultation with the HIT Policy Committee and the HIT
Standards Committee, shall develop interoperable and secure
standards and protocols that facilitate enrollment of
individuals in Federal and State health and human services
programs, as determined by the Secretary.
``(2) Methods.--The Secretary shall facilitate enrollment
in such programs through methods determined appropriate by
the Secretary, which shall include providing individuals and
third parties authorized by such individuals and their
designees notification of eligibility and verification of
eligibility required under such programs.
``(b) Content.--The standards and protocols for electronic
enrollment in the Federal and State programs described in
subsection (a) shall allow for the following:
``(1) Electronic matching against existing Federal and
State data, including vital records, employment history,
enrollment systems, tax records, and other data determined
appropriate by the Secretary to serve as evidence of
eligibility and in lieu of paper-based documentation.
``(2) Simplification and submission of electronic
documentation, digitization of documents, and systems
verification of eligibility.
``(3) Reuse of stored eligibility information (including
documentation) to assist with retention of eligible
individuals.
``(4) Capability for individuals to apply, recertify and
manage their eligibility information online, including at
home, at points of service, and other community-based
locations.
``(5) Ability to expand the enrollment system to integrate
new programs, rules, and functionalities, to operate at
increased volume, and to apply streamlined verification and
eligibility processes to other Federal and State programs, as
appropriate.
``(6) Notification of eligibility, recertification, and
other needed communication regarding eligibility, which may
include communication via email and cellular phones.
``(7) Other functionalities necessary to provide eligibles
with streamlined enrollment process.
``(c) Approval and Notification.--With respect to any
standard or protocol developed under subsection (a) that has
been approved by the HIT Policy Committee and the HIT
Standards Committee, the Secretary--
``(1) shall notify States of such standards or protocols;
and
``(2) may require, as a condition of receiving Federal
funds for the health information technology investments, that
States or other entities incorporate such standards and
protocols into such investments.
``(d) Grants for Implementation of Appropriate Enrollment
HIT.--
``(1) In general.--The Secretary shall award grant to
eligible entities to develop new, and adapt existing,
technology systems to implement the HIT enrollment standards
and protocols developed under subsection (a) (referred to in
this subsection as `appropriate HIT technology').
``(2) Eligible entities.--To be eligible for a grant under
this subsection, an entity shall--
``(A) be a State, political subdivision of a State, or a
local governmental entity; and
``(B) submit to the Secretary an application at such time,
in such manner, and containing--
``(i) a plan to adopt and implement appropriate enrollment
technology that includes--
``(I) proposed reduction in maintenance costs of technology
systems;
``(II) elimination or updating of legacy systems; and
``(III) demonstrated collaboration with other entities that
may receive a grant under this section that are located in
the same State, political subdivision, or locality;
``(ii) an assurance that the entity will share such
appropriate enrollment technology in accordance with
paragraph (4); and
``(iii) such other information as the Secretary may
require.
``(3) Sharing.--
``(A) In general.--The Secretary shall ensure that
appropriate enrollment HIT adopted under grants under this
subsection is made available to other qualified State,
qualified political subdivisions of a State, or other
appropriate qualified entities (as described in subparagraph
(B)) at no cost.
``(B) Qualified entities.--The Secretary shall determine
what entities are qualified to receive enrollment HIT under
subparagraph (A), taking into consideration the
recommendations of the HIT Policy Committee and the HIT
Standards Committee.''.
[[Page H1959]]
SEC. 1562. CONFORMING AMENDMENTS.
(a) Applicability.--Section 2735 of the Public Health
Service Act (42 U.S.C. 300gg-21), as so redesignated by
section 1001(4), is amended--
(1) by striking subsection (a);
(2) in subsection (b)--
(A) in paragraph (1), by striking ``1 through 3'' and
inserting ``1 and 2''; and
(B) in paragraph (2)--
(i) in subparagraph (A), by striking ``subparagraph (D)''
and inserting ``subparagraph (D) or (E)'';
(ii) by striking ``1 through 3'' and inserting ``1 and 2'';
and
(iii) by adding at the end the following:
``(E) Election not applicable.--The election described in
subparagraph (A) shall not be available with respect to the
provisions of subpart 1.'';
(3) in subsection (c), by striking ``1 through 3 shall not
apply to any group'' and inserting ``1 and 2 shall not apply
to any individual coverage or any group''; and
(4) in subsection (d)--
(A) in paragraph (1), by striking ``1 through 3 shall not
apply to any group'' and inserting ``1 and 2 shall not apply
to any individual coverage or any group'';
(B) in paragraph (2)--
(i) in the matter preceding subparagraph (A), by striking
``1 through 3 shall not apply to any group'' and inserting
``1 and 2 shall not apply to any individual coverage or any
group''; and
(ii) in subparagraph (C), by inserting ``or, with respect
to individual coverage, under any health insurance coverage
maintained by the same health insurance issuer''; and
(C) in paragraph (3), by striking ``any group'' and
inserting ``any individual coverage or any group''.
(b) Definitions.--Section 2791(d) of the Public Health
Service Act (42 U.S.C. 300gg-91(d)) is amended by adding at
the end the following:
``(20) Qualified health plan.--The term `qualified health
plan' has the meaning given such term in section 1301(a) of
the Patient Protection and Affordable Care Act.
``(21) Exchange.--The term `Exchange' means an American
Health Benefit Exchange established under section 1311 of the
Patient Protection and Affordable Care Act.''.
(c) Technical and Conforming Amendments.--Title XXVII of
the Public Health Service Act (42 U.S.C. 300gg et seq.) is
amended--
(1) in section 2704 (42 U.S.C. 300gg), as so redesignated
by section 1201(2)--
(A) in subsection (c)--
(i) in paragraph (2), by striking ``group health plan''
each place that such term appears and inserting ``group or
individual health plan''; and
(ii) in paragraph (3)--
(I) by striking ``group health insurance'' each place that
such term appears and inserting ``group or individual health
insurance''; and
(II) in subparagraph (D), by striking ``small or large''
and inserting ``individual or group'';
(B) in subsection (d), by striking ``group health
insurance'' each place that such term appears and inserting
``group or individual health insurance''; and
(C) in subsection (e)(1)(A), by striking ``group health
insurance'' and inserting ``group or individual health
insurance'';
(2) by striking the second heading for subpart 2 of part A
(relating to other requirements);
(3) in section 2725 (42 U.S.C. 300gg-4), as so redesignated
by section 1001(2)--
(A) in subsection (a), by striking ``health insurance
issuer offering group health insurance coverage'' and
inserting ``health insurance issuer offering group or
individual health insurance coverage'';
(B) in subsection (b)--
(i) by striking ``health insurance issuer offering group
health insurance coverage in connection with a group health
plan'' in the matter preceding paragraph (1) and inserting
``health insurance issuer offering group or individual health
insurance coverage''; and
(ii) in paragraph (1), by striking ``plan'' and inserting
``plan or coverage'';
(C) in subsection (c)--
(i) in paragraph (2), by striking ``group health insurance
coverage offered by a health insurance issuer'' and inserting
``health insurance issuer offering group or individual health
insurance coverage''; and
(ii) in paragraph (3), by striking ``issuer'' and inserting
``health insurance issuer''; and
(D) in subsection (e), by striking ``health insurance
issuer offering group health insurance coverage'' and
inserting ``health insurance issuer offering group or
individual health insurance coverage'';
(4) in section 2726 (42 U.S.C. 300gg-5), as so redesignated
by section 1001(2)--
(A) in subsection (a), by striking ``(or health insurance
coverage offered in connection with such a plan)'' each place
that such term appears and inserting ``or a health insurance
issuer offering group or individual health insurance
coverage'';
(B) in subsection (b), by striking ``(or health insurance
coverage offered in connection with such a plan)'' each place
that such term appears and inserting ``or a health insurance
issuer offering group or individual health insurance
coverage''; and
(C) in subsection (c)--
(i) in paragraph (1), by striking ``(and group health
insurance coverage offered in connection with a group health
plan)'' and inserting ``and a health insurance issuer
offering group or individual health insurance coverage'';
(ii) in paragraph (2), by striking ``(or health insurance
coverage offered in connection with such a plan)'' each place
that such term appears and inserting ``or a health insurance
issuer offering group or individual health insurance
coverage'';
(5) in section 2727 (42 U.S.C. 300gg-6), as so redesignated
by section 1001(2), by striking ``health insurance issuers
providing health insurance coverage in connection with group
health plans'' and inserting ``and health insurance issuers
offering group or individual health insurance coverage'';
(6) in section 2728 (42 U.S.C. 300gg-7), as so redesignated
by section 1001(2)--
(A) in subsection (a), by striking ``health insurance
coverage offered in connection with such plan'' and inserting
``individual health insurance coverage'';
(B) in subsection (b)--
(i) in paragraph (1), by striking ``or a health insurance
issuer that provides health insurance coverage in connection
with a group health plan'' and inserting ``or a health
insurance issuer that offers group or individual health
insurance coverage'';
(ii) in paragraph (2), by striking ``health insurance
coverage offered in connection with the plan'' and inserting
``individual health insurance coverage''; and
(iii) in paragraph (3), by striking ``health insurance
coverage offered by an issuer in connection with such plan''
and inserting ``individual health insurance coverage'';
(C) in subsection (c), by striking ``health insurance
issuer providing health insurance coverage in connection with
a group health plan'' and inserting ``health insurance issuer
that offers group or individual health insurance coverage'';
and
(D) in subsection (e)(1), by striking ``health insurance
coverage offered in connection with such a plan'' and
inserting ``individual health insurance coverage'';
(7) by striking the heading for subpart 3;
(8) in section 2731 (42 U.S.C. 300gg-11), as so
redesignated by section 1001(3)--
(A) by striking the section heading and all that follows
through subsection (b);
(B) in subsection (c)--
(i) in paragraph (1)--
(I) in the matter preceding subparagraph (A), by striking
``small group'' and inserting ``group and individual''; and
(II) in subparagraph (B)--
(aa) in the matter preceding clause (i), by inserting ``and
individuals'' after ``employers'';
(bb) in clause (i), by inserting ``or any additional
individuals'' after ``additional groups''; and
(cc) in clause (ii), by striking ``without regard to the
claims experience of those employers and their employees (and
their dependents) or any health status-related factor
relating to such'' and inserting ``and individuals without
regard to the claims experience of those individuals,
employers and their employees (and their dependents) or any
health status-related factor relating to such individuals'';
and
(ii) in paragraph (2), by striking ``small group'' and
inserting ``group or individual'';
(C) in subsection (d)--
(i) by striking ``small group'' each place that such
appears and inserting ``group or individual''; and
(ii) in paragraph (1)(B)--
(I) by striking ``all employers'' and inserting ``all
employers and individuals'';
(II) by striking ``those employers'' and inserting ``those
individuals, employers''; and
(III) by striking ``such employees'' and inserting ``such
individuals, employees'';
(D) by striking subsection (e);
(E) by striking subsection (f); and
(F) by transferring such section (as amended by this
paragraph) to appear at the end of section 2702 (as added by
section 1001(4));
(9) in section 2732 (42 U.S.C. 300gg-12), as so
redesignated by section 1001(3)--
(A) by striking the section heading and all that follows
through subsection (a);
(B) in subsection (b)--
(i) in the matter preceding paragraph (1), by striking
``group health plan in the small or large group market'' and
inserting ``health insurance coverage offered in the group or
individual market'';
(ii) in paragraph (1), by inserting ``, or individual, as
applicable,'' after ``plan sponsor'';
(iii) in paragraph (2), by inserting ``, or individual, as
applicable,'' after ``plan sponsor''; and
(iv) by striking paragraph (3) and inserting the following:
``(3) Violation of participation or contribution rates.--In
the case of a group health plan, the plan sponsor has failed
to comply with a material plan provision relating to employer
contribution or group participation rules, pursuant to
applicable State law.'';
(C) in subsection (c)--
(i) in paragraph (1)--
(I) in the matter preceding subparagraph (A), by striking
``group health insurance coverage offered in the small or
large group market'' and inserting ``group or individual
health insurance coverage'';
(II) in subparagraph (A), by inserting ``or individual, as
applicable,'' after ``plan sponsor'';
(III) in subparagraph (B)--
(aa) by inserting ``or individual, as applicable,'' after
``plan sponsor''; and
(bb) by inserting ``or individual health insurance
coverage''; and
(IV) in subparagraph (C), by inserting ``or individuals, as
applicable,'' after ``those sponsors''; and
(ii) in paragraph (2)(A)--
(I) in the matter preceding clause (i), by striking ``small
group market or the large group market, or both markets,''
and inserting ``individual or group market, or all
markets,''; and
(II) in clause (i), by inserting ``or individual, as
applicable,'' after ``plan sponsor''; and
(D) by transferring such section (as amended by this
paragraph) to appear at the end of section 2703 (as added by
section 1001(4));
(10) in section 2733 (42 U.S.C. 300gg-13), as so
redesignated by section 1001(4)--
[[Page H1960]]
(A) in subsection (a)--
(i) in the matter preceding paragraph (1), by striking
``small employer'' and inserting ``small employer or an
individual'';
(ii) in paragraph (1), by inserting ``, or individual, as
applicable,'' after ``employer'' each place that such
appears; and
(iii) in paragraph (2), by striking ``small employer'' and
inserting ``employer, or individual, as applicable,'';
(B) in subsection (b)--
(i) in paragraph (1)--
(I) in the matter preceding subparagraph (A), by striking
``small employer'' and inserting ``employer, or individual,
as applicable,'';
(II) in subparagraph (A), by adding ``and'' at the end;
(III) by striking subparagraphs (B) and (C); and
(IV) in subparagraph (D)--
(aa) by inserting ``, or individual, as applicable,'' after
``employer''; and
(bb) by redesignating such subparagraph as subparagraph
(B);
(ii) in paragraph (2)--
(I) by striking ``small employers'' each place that such
term appears and inserting ``employers, or individuals, as
applicable,''; and
(II) by striking ``small employer'' and inserting
``employer, or individual, as applicable,''; and
(C) by redesignating such section (as amended by this
paragraph) as section 2709 and transferring such section to
appear after section 2708 (as added by section 1001(5));
(11) by redesignating subpart 4 as subpart 2;
(12) in section 2735 (42 U.S.C. 300gg-21), as so
redesignated by section 1001(4)--
(A) by striking subsection (a);
(B) by striking ``subparts 1 through 3'' each place that
such appears and inserting ``subpart 1'';
(C) by redesignating subsections (b) through (e) as
subsections (a) through (d), respectively; and
(D) by redesignating such section (as amended by this
paragraph) as section 2722;
(13) in section 2736 (42 U.S.C. 300gg-22), as so
redesignated by section 1001(4)--
(A) in subsection (a)--
(i) in paragraph (1), by striking ``small or large group
markets'' and inserting ``individual or group market''; and
(ii) in paragraph (2), by inserting ``or individual health
insurance coverage'' after ``group health plans'';
(B) in subsection (b)(1)(B), by inserting ``individual
health insurance coverage or'' after ``respect to''; and
(C) by redesignating such section (as amended by this
paragraph) as section 2723;
(14) in section 2737(a)(1) (42 U.S.C. 300gg-23), as so
redesignated by section 1001(4)--
(A) by inserting ``individual or'' before ``group health
insurance''; and
(B) by redesignating such section(as amended by this
paragraph) as section 2724;
(15) in section 2762 (42 U.S.C. 300gg-62)--
(A) in the section heading by inserting ``AND APPLICATION''
before the period; and
(B) by adding at the end the following:
``(c) Application of Part A Provisions.--
``(1) In general.--The provisions of part A shall apply to
health insurance issuers providing health insurance coverage
in the individual market in a State as provided for in such
part.
``(2) Clarification.--To the extent that any provision of
this part conflicts with a provision of part A with respect
to health insurance issuers providing health insurance
coverage in the individual market in a State, the provisions
of such part A shall apply.''; and
(16) in section 2791(e) (42 U.S.C. 300gg-91(e))--
(A) in paragraph (2), by striking ``51'' and inserting
``101''; and
(B) in paragraph (4)--
(i) by striking ``at least 2'' each place that such appears
and inserting ``at least 1''; and
(ii) by striking ``50'' and inserting ``100''.
(d) Application.--Notwithstanding any other provision of
the Patient Protection and Affordable Care Act, nothing in
such Act (or an amendment made by such Act) shall be
construed to--
(1) prohibit (or authorize the Secretary of Health and
Human Services to promulgate regulations that prohibit) a
group health plan or health insurance issuer from carrying
out utilization management techniques that are commonly used
as of the date of enactment of this Act; or
(2) restrict the application of the amendments made by this
subtitle.
(e) Technical Amendment to the Employee Retirement Income
Security Act of 1974.--Subpart B of part 7 of subtitle A of
title I of the Employee Retirement Income Security Act of
1974 (29 U.S.C. 1181 et. seq.) is amended, by adding at the
end the following:
``SEC. 715. ADDITIONAL MARKET REFORMS.
``(a) General Rule.--Except as provided in subsection (b)--
``(1) the provisions of part A of title XXVII of the Public
Health Service Act (as amended by the Patient Protection and
Affordable Care Act) shall apply to group health plans, and
health insurance issuers providing health insurance coverage
in connection with group health plans, as if included in this
subpart; and
``(2) to the extent that any provision of this part
conflicts with a provision of such part A with respect to
group health plans, or health insurance issuers providing
health insurance coverage in connection with group health
plans, the provisions of such part A shall apply.
``(b) Exception.--Notwithstanding subsection (a), the
provisions of sections 2716 and 2718 of title XXVII of the
Public Health Service Act (as amended by the Patient
Protection and Affordable Care Act) shall not apply with
respect to self-insured group health plans, and the
provisions of this part shall continue to apply to such plans
as if such sections of the Public Health Service Act (as so
amended) had not been enacted.''.
(f) Technical Amendment to the Internal Revenue Code of
1986.--Subchapter B of chapter 100 of the Internal Revenue
Code of 1986 is amended by adding at the end the following:
``SEC. 9815. ADDITIONAL MARKET REFORMS.
``(a) General Rule.--Except as provided in subsection (b)--
``(1) the provisions of part A of title XXVII of the Public
Health Service Act (as amended by the Patient Protection and
Affordable Care Act) shall apply to group health plans, and
health insurance issuers providing health insurance coverage
in connection with group health plans, as if included in this
subchapter; and
``(2) to the extent that any provision of this subchapter
conflicts with a provision of such part A with respect to
group health plans, or health insurance issuers providing
health insurance coverage in connection with group health
plans, the provisions of such part A shall apply.
``(b) Exception.--Notwithstanding subsection (a), the
provisions of sections 2716 and 2718 of title XXVII of the
Public Health Service Act (as amended by the Patient
Protection and Affordable Care Act) shall not apply with
respect to self-insured group health plans, and the
provisions of this subchapter shall continue to apply to such
plans as if such sections of the Public Health Service Act
(as so amended) had not been enacted.''.
SEC. 1563. SENSE OF THE SENATE PROMOTING FISCAL
RESPONSIBILITY.
(a) Findings.--The Senate makes the following findings:
(1) Based on Congressional Budget Office (CBO) estimates,
this Act will reduce the Federal deficit between 2010 and
2019.
(2) CBO projects this Act will continue to reduce budget
deficits after 2019.
(3) Based on CBO estimates, this Act will extend the
solvency of the Medicare HI Trust Fund.
(4) This Act will increase the surplus in the Social
Security Trust Fund, which should be reserved to strengthen
the finances of Social Security.
(5) The initial net savings generated by the Community
Living Assistance Services and Supports (CLASS) program are
necessary to ensure the long-term solvency of that program.
(b) Sense of the Senate.--It is the sense of the Senate
that--
(1) the additional surplus in the Social Security Trust
Fund generated by this Act should be reserved for Social
Security and not spent in this Act for other purposes; and
(2) the net savings generated by the CLASS program should
be reserved for the CLASS program and not spent in this Act
for other purposes.
TITLE II--ROLE OF PUBLIC PROGRAMS
Subtitle A--Improved Access to Medicaid
SEC. 2001. MEDICAID COVERAGE FOR THE LOWEST INCOME
POPULATIONS.
(a) Coverage for Individuals With Income at or Below 133
Percent of the Poverty Line.--
(1) Beginning 2014.--Section 1902(a)(10)(A)(i) of the
Social Security Act (42 U.S.C. 1396a) is amended--
(A) by striking ``or'' at the end of subclause (VI);
(B) by adding ``or'' at the end of subclause (VII); and
(C) by inserting after subclause (VII) the following:
``(VIII) beginning January 1, 2014, who are under 65 years
of age, not pregnant, not entitled to, or enrolled for,
benefits under part A of title XVIII, or enrolled for
benefits under part B of title XVIII, and are not described
in a previous subclause of this clause, and whose income (as
determined under subsection (e)(14)) does not exceed 133
percent of the poverty line (as defined in section
2110(c)(5)) applicable to a family of the size involved,
subject to subsection (k);''.
(2) Provision of at least minimum essential coverage.--
(A) In general.--Section 1902 of such Act (42 U.S.C. 1396a)
is amended by inserting after subsection (j) the following:
``(k)(1) The medical assistance provided to an individual
described in subclause (VIII) of subsection (a)(10)(A)(i)
shall consist of benchmark coverage described in section
1937(b)(1) or benchmark equivalent coverage described in
section 1937(b)(2). Such medical assistance shall be provided
subject to the requirements of section 1937, without regard
to whether a State otherwise has elected the option to
provide medical assistance through coverage under that
section, unless an individual described in subclause (VIII)
of subsection (a)(10)(A)(i) is also an individual for whom,
under subparagraph (B) of section 1937(a)(2), the State may
not require enrollment in benchmark coverage described in
subsection (b)(1) of section 1937 or benchmark equivalent
coverage described in subsection (b)(2) of that section.''.
(B) Conforming amendment.--Section 1903(i) of the Social
Security Act, as amended by section 6402(c), is amended--
(i) in paragraph (24), by striking ``or'' at the end;
(ii) in paragraph (25), by striking the period and
inserting ``; or''; and
(iii) by adding at the end the following:
``(26) with respect to any amounts expended for medical
assistance for individuals described in subclause (VIII) of
subsection (a)(10)(A)(i) other than medical assistance
provided through benchmark coverage described in section
1937(b)(1) or benchmark equivalent coverage described in
section 1937(b)(2).''.
(3) Federal funding for cost of covering newly eligible
individuals.--Section 1905 of the Social Security Act (42
U.S.C. 1396d), is amended--
(A) in subsection (b), in the first sentence, by inserting
``subsection (y) and'' before ``section 1933(d)''; and
[[Page H1961]]
(B) by adding at the end the following new subsection:
``(y) Increased FMAP for Medical Assistance for Newly
Eligible Mandatory Individuals.--
``(1) Amount of increase.--
``(A) 100 percent fmap.--During the period that begins on
January 1, 2014, and ends on December 31, 2016,
notwithstanding subsection (b), the Federal medical
assistance percentage determined for a State that is one of
the 50 States or the District of Columbia for each fiscal
year occurring during that period with respect to amounts
expended for medical assistance for newly eligible
individuals described in subclause (VIII) of section
1902(a)(10)(A)(i) shall be equal to 100 percent.
``(B) 2017 and 2018.--
``(i) In general.--During the period that begins on January
1, 2017, and ends on December 31, 2018, notwithstanding
subsection (b) and subject to subparagraph (D), the Federal
medical assistance percentage determined for a State that is
one of the 50 States or the District of Columbia for each
fiscal year occurring during that period with respect to
amounts expended for medical assistance for newly eligible
individuals described in subclause (VIII) of section
1902(a)(10)(A)(i), shall be increased by the applicable
percentage point increase specified in clause (ii) for the
quarter and the State.
``(ii) Applicable percentage point increase.--
``(I) In general.--For purposes of clause (i), the
applicable percentage point increase for a quarter is the
following:
----------------------------------------------------------------------------------------------------------------
If the State is an expansion State, If the State is not an expansion
``For any fiscal year quarter the applicable percentage point State, the applicable percentage
occurring in the calendar year: increase is: point increase is:
----------------------------------------------------------------------------------------------------------------
2017 30.3 34.3
----------------------------------------------------------------------------------------------------------------
2018 31.3 33.3
----------------------------------------------------------------------------------------------------------------
``(II) Expansion state defined.--For purposes of the table
in subclause (I), a State is an expansion State if, on the
date of the enactment of the Patient Protection and
Affordable Care Act, the State offers health benefits
coverage statewide to parents and nonpregnant, childless
adults whose income is at least 100 percent of the poverty
line, that is not dependent on access to employer coverage,
employer contribution, or employment and is not limited to
premium assistance, hospital-only benefits, a high deductible
health plan, or alternative benefits under a demonstration
program authorized under section 1938. A State that offers
health benefits coverage to only parents or only nonpregnant
childless adults described in the preceding sentence shall
not be considered to be an expansion State.
``(C) 2019 and succeeding years.--Beginning January 1,
2019, notwithstanding subsection (b) but subject to
subparagraph (D), the Federal medical assistance percentage
determined for a State that is one of the 50 States or the
District of Columbia for each fiscal year quarter occurring
during that period with respect to amounts expended for
medical assistance for newly eligible individuals described
in subclause (VIII) of section 1902(a)(10)(A)(i), shall be
increased by 32.3 percentage points.
``(D) Limitation.--The Federal medical assistance
percentage determined for a State under subparagraph (B) or
(C) shall in no case be more than 95 percent.
``(2) Definitions.--In this subsection:
``(A) Newly eligible.--The term `newly eligible' means,
with respect to an individual described in subclause (VIII)
of section 1902(a)(10)(A)(i), an individual who is not under
19 years of age (or such higher age as the State may have
elected) and who, on the date of enactment of the Patient
Protection and Affordable Care Act, is not eligible under the
State plan or under a waiver of the plan for full benefits or
for benchmark coverage described in subparagraph (A), (B), or
(C) of section 1937(b)(1) or benchmark equivalent coverage
described in section 1937(b)(2) that has an aggregate
actuarial value that is at least actuarially equivalent to
benchmark coverage described in subparagraph (A), (B), or (C)
of section 1937(b)(1), or is eligible but not enrolled (or is
on a waiting list) for such benefits or coverage through a
waiver under the plan that has a capped or limited enrollment
that is full.
``(B) Full benefits.--The term `full benefits' means, with
respect to an individual, medical assistance for all services
covered under the State plan under this title that is not
less in amount, duration, or scope, or is determined by the
Secretary to be substantially equivalent, to the medical
assistance available for an individual described in section
1902(a)(10)(A)(i).''.
(4) State options to offer coverage earlier and presumptive
eligibility; children required to have coverage for parents
to be eligible.--
(A) In general.--Subsection (k) of section 1902 of the
Social Security Act (as added by paragraph (2)), is amended
by inserting after paragraph (1) the following:
``(2) Beginning with the first day of any fiscal year
quarter that begins on or after January 1, 2011, and before
January 1, 2014, a State may elect through a State plan
amendment to provide medical assistance to individuals who
would be described in subclause (VIII) of subsection
(a)(10)(A)(i) if that subclause were effective before January
1, 2014. A State may elect to phase-in the extension of
eligibility for medical assistance to such individuals based
on income, so long as the State does not extend such
eligibility to individuals described in such subclause with
higher income before making individuals described in such
subclause with lower income eligible for medical assistance.
``(3) If an individual described in subclause (VIII) of
subsection (a)(10)(A)(i) is the parent of a child who is
under 19 years of age (or such higher age as the State may
have elected) who is eligible for medical assistance under
the State plan or under a waiver of such plan (under that
subclause or under a State plan amendment under paragraph
(2), the individual may not be enrolled under the State plan
unless the individual's child is enrolled under the State
plan or under a waiver of the plan or is enrolled in other
health insurance coverage. For purposes of the preceding
sentence, the term `parent' includes an individual treated as
a caretaker relative for purposes of carrying out section
1931.''.
(B) Presumptive eligibility.--Section 1920 of the Social
Security Act (42 U.S.C. 1396r-1) is amended by adding at the
end the following:
``(e) If the State has elected the option to provide a
presumptive eligibility period under this section or section
1920A, the State may elect to provide a presumptive
eligibility period (as defined in subsection (b)(1)) for
individuals who are eligible for medical assistance under
clause (i)(VIII) of subsection (a)(10)(A) or section 1931 in
the same manner as the State provides for such a period under
this section or section 1920A, subject to such guidance as
the Secretary shall establish.''.
(5) Conforming amendments.--
(A) Section 1902(a)(10) of such Act (42 U.S.C.
1396a(a)(10)) is amended in the matter following subparagraph
(G), by striking ``and (XIV)'' and inserting ``(XIV)'' and by
inserting ``and (XV) the medical assistance made available to
an individual described in subparagraph (A)(i)(VIII) shall be
limited to medical assistance described in subsection
(k)(1)'' before the semicolon.
(B) Section 1902(l)(2)(C) of such Act (42 U.S.C.
1396a(l)(2)(C)) is amended by striking ``100'' and inserting
``133''.
(C) Section 1905(a) of such Act (42 U.S.C. 1396d(a)) is
amended in the matter preceding paragraph (1)--
(i) by striking ``or'' at the end of clause (xii);
(ii) by inserting ``or'' at the end of clause (xiii); and
(iii) by inserting after clause (xiii) the following:
``(xiv) individuals described in section
1902(a)(10)(A)(i)(VIII),''.
(D) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4))
is amended by inserting ``1902(a)(10)(A)(i)(VIII),'' after
``1902(a)(10)(A)(i)(VII),''.
(E) Section 1937(a)(1)(B) of such Act (42 U.S.C. 1396u-
7(a)(1)(B)) is amended by inserting ``subclause (VIII) of
section 1902(a)(10)(A)(i) or under'' after ``eligible
under''.
(b) Maintenance of Medicaid Income Eligibility.--Section
1902 of the Social Security Act (42 U.S.C. 1396a) is
amended--
(1) in subsection (a)--
(A) by striking ``and'' at the end of paragraph (72);
(B) by striking the period at the end of paragraph (73) and
inserting ``; and''; and
(C) by inserting after paragraph (73) the following new
paragraph:
``(74) provide for maintenance of effort under the State
plan or under any waiver of the plan in accordance with
subsection (gg).''; and
(2) by adding at the end the following new subsection:
``(gg) Maintenance of Effort.--
``(1) General requirement to maintain eligibility standards
until state exchange is fully operational.--Subject to the
succeeding paragraphs of this subsection, during the period
that begins on the date of enactment of the Patient
Protection and Affordable Care Act and ends on the date on
which the Secretary determines that an Exchange established
by the State under section 1311 of the Patient Protection and
Affordable Care Act is fully operational, as a condition for
receiving any Federal payments under section 1903(a) for
calendar quarters occurring during such period, a State shall
not have in effect eligibility standards, methodologies, or
procedures under the State plan under this title or under any
waiver of such plan that is in effect during that period,
that are more restrictive than the eligibility standards,
methodologies, or procedures, respectively, under the plan or
waiver that are in effect on the date of enactment of the
Patient Protection and Affordable Care Act.
``(2) Continuation of eligibility standards for children
until october 1, 2019.--The requirement under paragraph (1)
shall continue to apply to a State through September 30,
2019, with respect to the eligibility standards,
methodologies, and procedures under the State plan under this
title or under any waiver of such plan that are applicable to
determining the eligibility for medical assistance of any
child who is under 19 years of age (or such higher age as the
State may have elected).
``(3) Nonapplication.--During the period that begins on
January 1, 2011, and ends on December 31, 2013, the
requirement under paragraph (1) shall not apply to a State
with respect to nonpregnant, nondisabled adults who are
eligible for medical assistance under the State plan or under
a waiver of the plan at the option of the State and whose
income exceeds 133 percent of the poverty line (as defined in
section 2110(c)(5)) applicable to a family of the size
involved if, on or after December 31, 2010, the
[[Page H1962]]
State certifies to the Secretary that, with respect to the
State fiscal year during which the certification is made, the
State has a budget deficit, or with respect to the succeeding
State fiscal year, the State is projected to have a budget
deficit. Upon submission of such a certification to the
Secretary, the requirement under paragraph (1) shall not
apply to the State with respect to any remaining portion of
the period described in the preceding sentence.
``(4) Determination of compliance.--
``(A) States shall apply modified gross income.--A State's
determination of income in accordance with subsection (e)(14)
shall not be considered to be eligibility standards,
methodologies, or procedures that are more restrictive than
the standards, methodologies, or procedures in effect under
the State plan or under a waiver of the plan on the date of
enactment of the Patient Protection and Affordable Care Act
for purposes of determining compliance with the requirements
of paragraph (1), (2), or (3).
``(B) States may expand eligibility or move waivered
populations into coverage under the state plan.--With respect
to any period applicable under paragraph (1), (2), or (3), a
State that applies eligibility standards, methodologies, or
procedures under the State plan under this title or under any
waiver of the plan that are less restrictive than the
eligibility standards, methodologies, or procedures, applied
under the State plan or under a waiver of the plan on the
date of enactment of the Patient Protection and Affordable
Care Act, or that makes individuals who, on such date of
enactment, are eligible for medical assistance under a waiver
of the State plan, after such date of enactment eligible for
medical assistance through a State plan amendment with an
income eligibility level that is not less than the income
eligibility level that applied under the waiver, or as a
result of the application of subclause (VIII) of section
1902(a)(10)(A)(i), shall not be considered to have in effect
eligibility standards, methodologies, or procedures that are
more restrictive than the standards, methodologies, or
procedures in effect under the State plan or under a waiver
of the plan on the date of enactment of the Patient
Protection and Affordable Care Act for purposes of
determining compliance with the requirements of paragraph
(1), (2), or (3).''.
(c) Medicaid Benchmark Benefits Must Consist of at Least
Minimum Essential Coverage.--Section 1937(b) of such Act (42
U.S.C. 1396u-7(b)) is amended--
(1) in paragraph (1), in the matter preceding subparagraph
(A), by inserting ``subject to paragraphs (5) and (6),''
before ``each'';
(2) in paragraph (2)--
(A) in the matter preceding subparagraph (A), by inserting
``subject to paragraphs (5) and (6)'' after ``subsection
(a)(1),'';
(B) in subparagraph (A)--
(i) by redesignating clauses (iv) and (v) as clauses (vi)
and (vii), respectively; and
(ii) by inserting after clause (iii), the following:
``(iv) Coverage of prescription drugs.
``(v) Mental health services.''; and
(C) in subparagraph (C)--
(i) by striking clauses (i) and (ii); and
(ii) by redesignating clauses (iii) and (iv) as clauses (i)
and (ii), respectively; and
(3) by adding at the end the following new paragraphs:
``(5) Minimum standards.--Effective January 1, 2014, any
benchmark benefit package under paragraph (1) or benchmark
equivalent coverage under paragraph (2) must provide at least
essential health benefits as described in section 1302(b) of
the Patient Protection and Affordable Care Act.
``(6) Mental health services parity.--
``(A) In general.--In the case of any benchmark benefit
package under paragraph (1) or benchmark equivalent coverage
under paragraph (2) that is offered by an entity that is not
a medicaid managed care organization and that provides both
medical and surgical benefits and mental health or substance
use disorder benefits, the entity shall ensure that the
financial requirements and treatment limitations applicable
to such mental health or substance use disorder benefits
comply with the requirements of section 2705(a) of the Public
Health Service Act in the same manner as such requirements
apply to a group health plan.
``(B) Deemed compliance.--Coverage provided with respect to
an individual described in section 1905(a)(4)(B) and covered
under the State plan under section 1902(a)(10)(A) of the
services described in section 1905(a)(4)(B) (relating to
early and periodic screening, diagnostic, and treatment
services defined in section 1905(r)) and provided in
accordance with section 1902(a)(43), shall be deemed to
satisfy the requirements of subparagraph (A).''.
(d) Annual Reports on Medicaid Enrollment.--
(1) State reports.--Section 1902(a) of the Social Security
Act (42 U.S.C. 1396a(a)), as amended by subsection (b), is
amended--
(A) by striking ``and'' at the end of paragraph (73);
(B) by striking the period at the end of paragraph (74) and
inserting ``; and''; and
(C) by inserting after paragraph (74) the following new
paragraph:
``(75) provide that, beginning January 2015, and annually
thereafter, the State shall submit a report to the Secretary
that contains--
``(A) the total number of enrolled and newly enrolled
individuals in the State plan or under a waiver of the plan
for the fiscal year ending on September 30 of the preceding
calendar year, disaggregated by population, including
children, parents, nonpregnant childless adults, disabled
individuals, elderly individuals, and such other categories
or sub-categories of individuals eligible for medical
assistance under the State plan or under a waiver of the plan
as the Secretary may require;
``(B) a description, which may be specified by population,
of the outreach and enrollment processes used by the State
during such fiscal year; and
``(C) any other data reporting determined necessary by the
Secretary to monitor enrollment and retention of individuals
eligible for medical assistance under the State plan or under
a waiver of the plan.''.
(2) Reports to congress.--Beginning April 2015, and
annually thereafter, the Secretary of Health and Human
Services shall submit a report to the appropriate committees
of Congress on the total enrollment and new enrollment in
Medicaid for the fiscal year ending on September 30 of the
preceding calendar year on a national and State-by-State
basis, and shall include in each such report such
recommendations for administrative or legislative changes to
improve enrollment in the Medicaid program as the Secretary
determines appropriate.
(e) State Option for Coverage for Individuals With Income
That Exceeds 133 Percent of the Poverty Line.--
(1) Coverage as optional categorically needy group.--
Section 1902 of the Social Security Act (42 U.S.C. 1396a) is
amended--
(A) in subsection (a)(10)(A)(ii)--
(i) in subclause (XVIII), by striking ``or'' at the end;
(ii) in subclause (XIX), by adding ``or'' at the end; and
(iii) by adding at the end the following new subclause:
``(XX) beginning January 1, 2014, who are under 65 years of
age and are not described in or enrolled under a previous
subclause of this clause, and whose income (as determined
under subsection (e)(14)) exceeds 133 percent of the poverty
line (as defined in section 2110(c)(5)) applicable to a
family of the size involved but does not exceed the highest
income eligibility level established under the State plan or
under a waiver of the plan, subject to subsection (hh);'' and
(B) by adding at the end the following new subsection:
``(hh)(1) A State may elect to phase-in the extension of
eligibility for medical assistance to individuals described
in subclause (XX) of subsection (a)(10)(A)(ii) based on the
categorical group (including nonpregnant childless adults) or
income, so long as the State does not extend such eligibility
to individuals described in such subclause with higher income
before making individuals described in such subclause with
lower income eligible for medical assistance.
``(2) If an individual described in subclause (XX) of
subsection (a)(10)(A)(ii) is the parent of a child who is
under 19 years of age (or such higher age as the State may
have elected) who is eligible for medical assistance under
the State plan or under a waiver of such plan, the individual
may not be enrolled under the State plan unless the
individual's child is enrolled under the State plan or under
a waiver of the plan or is enrolled in other health insurance
coverage. For purposes of the preceding sentence, the term
`parent' includes an individual treated as a caretaker
relative for purposes of carrying out section 1931.''.
(2) Conforming amendments.--
(A) Section 1905(a) of such Act (42 U.S.C. 1396d(a)), as
amended by subsection (a)(5)(C), is amended in the matter
preceding paragraph (1)--
(i) by striking ``or'' at the end of clause (xiii);
(ii) by inserting ``or'' at the end of clause (xiv); and
(iii) by inserting after clause (xiv) the following:
``(xv) individuals described in section
1902(a)(10)(A)(ii)(XX),''.
(B) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4))
is amended by inserting ``1902(a)(10)(A)(ii)(XX),'' after
``1902(a)(10)(A)(ii)(XIX),''.
(C) Section 1920(e) of such Act (42 U.S.C. 1396r-1(e)), as
added by subsection (a)(4)(B), is amended by inserting ``or
clause (ii)(XX)'' after ``clause (i)(VIII)''.
SEC. 2002. INCOME ELIGIBILITY FOR NONELDERLY DETERMINED USING
MODIFIED GROSS INCOME.
(a) In General.--Section 1902(e) of the Social Security Act
(42 U.S.C. 1396a(e)) is amended by adding at the end the
following:
``(14) Income determined using modified gross income.--
``(A) In general.--Notwithstanding subsection (r) or any
other provision of this title, except as provided in
subparagraph (D), for purposes of determining income
eligibility for medical assistance under the State plan or
under any waiver of such plan and for any other purpose
applicable under the plan or waiver for which a determination
of income is required, including with respect to the
imposition of premiums and cost-sharing, a State shall use
the modified gross income of an individual and, in the case
of an individual in a family greater than 1, the household
income of such family. A State shall establish income
eligibility thresholds for populations to be eligible for
medical assistance under the State plan or a waiver of the
plan using modified gross income and household income that
are not less than the effective income eligibility levels
that applied under the State plan or waiver on the date of
enactment of the Patient Protection and Affordable Care Act.
For purposes of complying with the maintenance of effort
requirements under subsection (gg) during the transition to
modified gross income and household income, a State shall,
working with the Secretary, establish an equivalent income
test that ensures individuals eligible for medical assistance
under the State plan or under a waiver of the plan on the
date of enactment of the Patient Protection and Affordable
Care Act, do not lose coverage under the State plan or under
a waiver of the plan. The Secretary may waive such provisions
of this title and title XXI as are necessary to ensure
[[Page H1963]]
that States establish income and eligibility determination
systems that protect beneficiaries.
``(B) No income or expense disregards.--No type of expense,
block, or other income disregard shall be applied by a State
to determine income eligibility for medical assistance under
the State plan or under any waiver of such plan or for any
other purpose applicable under the plan or waiver for which a
determination of income is required.
``(C) No assets test.--A State shall not apply any assets
or resources test for purposes of determining eligibility for
medical assistance under the State plan or under a waiver of
the plan.
``(D) Exceptions.--
``(i) Individuals eligible because of other aid or
assistance, elderly individuals, medically needy individuals,
and individuals eligible for medicare cost-sharing.--
Subparagraphs (A), (B), and (C) shall not apply to the
determination of eligibility under the State plan or under a
waiver for medical assistance for the following:
``(I) Individuals who are eligible for medical assistance
under the State plan or under a waiver of the plan on a basis
that does not require a determination of income by the State
agency administering the State plan or waiver, including as a
result of eligibility for, or receipt of, other Federal or
State aid or assistance, individuals who are eligible on the
basis of receiving (or being treated as if receiving)
supplemental security income benefits under title XVI, and
individuals who are eligible as a result of being or being
deemed to be a child in foster care under the responsibility
of the State.
``(II) Individuals who have attained age 65.
``(III) Individuals who qualify for medical assistance
under the State plan or under any waiver of such plan on the
basis of being blind or disabled (or being treated as being
blind or disabled) without regard to whether the individual
is eligible for supplemental security income benefits under
title XVI on the basis of being blind or disabled and
including an individual who is eligible for medical
assistance on the basis of section 1902(e)(3).
``(IV) Individuals described in subsection (a)(10)(C).
``(V) Individuals described in any clause of subsection
(a)(10)(E).
``(ii) Express lane agency findings.--In the case of a
State that elects the Express Lane option under paragraph
(13), notwithstanding subparagraphs (A), (B), and (C), the
State may rely on a finding made by an Express Lane agency in
accordance with that paragraph relating to the income of an
individual for purposes of determining the individual's
eligibility for medical assistance under the State plan or
under a waiver of the plan.
``(iii) Medicare prescription drug subsidies
determinations.--Subparagraphs (A), (B), and (C) shall not
apply to any determinations of eligibility for premium and
cost-sharing subsidies under and in accordance with section
1860D-14 made by the State pursuant to section 1935(a)(2).
``(iv) Long-term care.--Subparagraphs (A), (B), and (C)
shall not apply to any determinations of eligibility of
individuals for purposes of medical assistance for nursing
facility services, a level of care in any institution
equivalent to that of nursing facility services, home or
community-based services furnished under a waiver or State
plan amendment under section 1915 or a waiver under section
1115, and services described in section 1917(c)(1)(C)(ii).
``(v) Grandfather of current enrollees until date of next
regular redetermination.--An individual who, on January 1,
2014, is enrolled in the State plan or under a waiver of the
plan and who would be determined ineligible for medical
assistance solely because of the application of the modified
gross income or household income standard described in
subparagraph (A), shall remain eligible for medical
assistance under the State plan or waiver (and subject to the
same premiums and cost-sharing as applied to the individual
on that date) through March 31, 2014, or the date on which
the individual's next regularly scheduled redetermination of
eligibility is to occur, whichever is later.
``(E) Transition planning and oversight.--Each State shall
submit to the Secretary for the Secretary's approval the
income eligibility thresholds proposed to be established
using modified gross income and household income, the
methodologies and procedures to be used to determine income
eligibility using modified gross income and household income
and, if applicable, a State plan amendment establishing an
optional eligibility category under subsection
(a)(10)(A)(ii)(XX). To the extent practicable, the State
shall use the same methodologies and procedures for purposes
of making such determinations as the State used on the date
of enactment of the Patient Protection and Affordable Care
Act. The Secretary shall ensure that the income eligibility
thresholds proposed to be established using modified gross
income and household income, including under the eligibility
category established under subsection (a)(10)(A)(ii)(XX), and
the methodologies and procedures proposed to be used to
determine income eligibility, will not result in children who
would have been eligible for medical assistance under the
State plan or under a waiver of the plan on the date of
enactment of the Patient Protection and Affordable Care Act
no longer being eligible for such assistance.
``(F) Limitation on secretarial authority.--The Secretary
shall not waive compliance with the requirements of this
paragraph except to the extent necessary to permit a State to
coordinate eligibility requirements for dual eligible
individuals (as defined in section 1915(h)(2)(B)) under the
State plan or under a waiver of the plan and under title
XVIII and individuals who require the level of care provided
in a hospital, a nursing facility, or an intermediate care
facility for the mentally retarded.
``(G) Definitions of modified gross income and household
income.--In this paragraph, the terms `modified gross income'
and `household income' have the meanings given such terms in
section 36B(d)(2) of the Internal Revenue Code of 1986.
``(H) Continued application of medicaid rules regarding
point-in-time income and sources of income.--The requirement
under this paragraph for States to use modified gross income
and household income to determine income eligibility for
medical assistance under the State plan or under any waiver
of such plan and for any other purpose applicable under the
plan or waiver for which a determination of income is
required shall not be construed as affecting or limiting the
application of--
``(i) the requirement under this title and under the State
plan or a waiver of the plan to determine an individual's
income as of the point in time at which an application for
medical assistance under the State plan or a waiver of the
plan is processed; or
``(ii) any rules established under this title or under the
State plan or a waiver of the plan regarding sources of
countable income.''.
(b) Conforming Amendment.--Section 1902(a)(17) of such Act
(42 U.S.C. 1396a(a)(17)) is amended by inserting ``(e)(14),''
before ``(l)(3)''.
(c) Effective Date.--The amendments made by subsections (a)
and (b) take effect on January 1, 2014.
SEC. 2003. REQUIREMENT TO OFFER PREMIUM ASSISTANCE FOR
EMPLOYER-SPONSORED INSURANCE.
(a) In General.--Section 1906A of such Act (42 U.S.C.
1396e-1) is amended--
(1) in subsection (a)--
(A) by striking ``may elect to'' and inserting ``shall'';
(B) by striking ``under age 19''; and
(C) by inserting ``, in the case of an individual under age
19,'' after ``(and'';
(2) in subsection (c), in the first sentence, by striking
``under age 19''; and
(3) in subsection (d)--
(A) in paragraph (2)--
(i) in the first sentence, by striking ``under age 19'';
and
(ii) by striking the third sentence and inserting ``A State
may not require, as a condition of an individual (or the
individual's parent) being or remaining eligible for medical
assistance under this title, that the individual (or the
individual's parent) apply for enrollment in qualified
employer-sponsored coverage under this section.''; and
(B) in paragraph (3), by striking ``the parent of an
individual under age 19'' and inserting ``an individual (or
the parent of an individual)''; and
(4) in subsection (e), by striking ``under age 19'' each
place it appears.
(b) Conforming Amendment.--The heading for section 1906A of
such Act (42 U.S.C. 1396e-1) is amended by striking ``option
for children''.
(c) Effective Date.--The amendments made by this section
take effect on January 1, 2014.
SEC. 2004. MEDICAID COVERAGE FOR FORMER FOSTER CARE CHILDREN.
(a) In General.--Section 1902(a)(10)(A)(i) of the Social
Security Act (42 U.S.C. 1396a), as amended by section
2001(a)(1), is amended--
(1) by striking ``or'' at the end of subclause (VII);
(2) by adding ``or'' at the end of subclause (VIII); and
(3) by inserting after subclause (VIII) the following:
``(IX) who were in foster care under the responsibility of
a State for more than 6 months (whether or not consecutive)
but are no longer in such care, who are not described in any
of subclauses (I) through (VII) of this clause, and who are
under 25 years of age;''.
(b) Option To Provide Presumptive Eligibility.--Section
1920(e) of such Act (42 U.S.C. 1396r-1(e)), as added by
section 2001(a)(4)(B) and amended by section 2001(e)(2)(C),
is amended by inserting ``, clause (i)(IX),'' after ``clause
(i)(VIII)''.
(c) Conforming Amendments.--
(1) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)),
as amended by section 2001(a)(5)(D), is amended by inserting
``1902(a)(10)(A)(i)(IX),'' after
``1902(a)(10)(A)(i)(VIII),''.
(2) Section 1937(a)(2)(B)(viii) of such Act (42 U.S.C.
1396u-7(a)(2)(B)(viii)) is amended by inserting ``, or the
individual qualifies for medical assistance on the basis of
section 1902(a)(10)(A)(i)(IX)'' before the period.
(d) Effective Date.--The amendments made by this section
take effect on January 1, 2019.
SEC. 2005. PAYMENTS TO TERRITORIES.
(a) Increase in Limit on Payments.--Section 1108(g) of the
Social Security Act (42 U.S.C. 1308(g)) is amended--
(1) in paragraph (2), in the matter preceding subparagraph
(A), by striking ``paragraph (3)'' and inserting ``paragraphs
(3) and (5)'';
(2) in paragraph (4), by striking ``and (3)'' and inserting
``(3), and (4)''; and
(3) by adding at the end the following paragraph:
``(5) Fiscal year 2011 and thereafter.--The amounts
otherwise determined under this subsection for Puerto Rico,
the Virgin Islands, Guam, the Northern Mariana Islands, and
American Samoa for the second, third, and fourth quarters of
fiscal year 2011, and for each fiscal year after fiscal year
2011 (after the application of subsection (f) and the
preceding paragraphs of this subsection), shall be increased
by 30 percent.''.
(b) Disregard of Payments for Mandatory Expanded
Enrollment.--Section 1108(g)(4) of such Act (42 U.S.C.
1308(g)(4)) is amended--
(1) by striking ``to fiscal years beginning'' and inserting
``to--
[[Page H1964]]
``(A) fiscal years beginning'';
(2) by striking the period at the end and inserting ``;
and''; and
(3) by adding at the end the following:
``(B) fiscal years beginning with fiscal year 2014,
payments made to Puerto Rico, the Virgin Islands, Guam, the
Northern Mariana Islands, or American Samoa with respect to
amounts expended for medical assistance for newly eligible
(as defined in section 1905(y)(2)) nonpregnant childless
adults who are eligible under subclause (VIII) of section
1902(a)(10)(A)(i) and whose income (as determined under
section 1902(e)(14)) does not exceed (in the case of each
such commonwealth and territory respectively) the income
eligibility level in effect for that population under title
XIX or under a waiver on the date of enactment of the Patient
Protection and Affordable Care Act, shall not be taken into
account in applying subsection (f) (as increased in
accordance with paragraphs (1), (2), (3), and (5) of this
subsection) to such commonwealth or territory for such fiscal
year.''.
(c) Increased FMAP.--
(1) In general.--The first sentence of section 1905(b) of
the Social Security Act (42 U.S.C. 1396d(b)) is amended by
striking ``shall be 50 per centum'' and inserting ``shall be
55 percent''.
(2) Effective date.--The amendment made by paragraph (1)
takes effect on January 1, 2011.
SEC. 2006. SPECIAL ADJUSTMENT TO FMAP DETERMINATION FOR
CERTAIN STATES RECOVERING FROM A MAJOR
DISASTER.
Section 1905 of the Social Security Act (42 U.S.C. 1396d),
as amended by sections 2001(a)(3) and 2001(b)(2), is
amended--
(1) in subsection (b), in the first sentence, by striking
``subsection (y)'' and inserting ``subsections (y) and
(aa)''; and
(2) by adding at the end the following new subsection:
``(aa)(1) Notwithstanding subsection (b), beginning January
1, 2011, the Federal medical assistance percentage for a
fiscal year for a disaster-recovery FMAP adjustment State
shall be equal to the following:
``(A) In the case of the first fiscal year (or part of a
fiscal year) for which this subsection applies to the State,
the Federal medical assistance percentage determined for the
fiscal year without regard to this subsection and subsection
(y), increased by 50 percent of the number of percentage
points by which the Federal medical assistance percentage
determined for the State for the fiscal year without regard
to this subsection and subsection (y), is less than the
Federal medical assistance percentage determined for the
State for the preceding fiscal year after the application of
only subsection (a) of section 5001 of Public Law 111-5 (if
applicable to the preceding fiscal year) and without regard
to this subsection, subsection (y), and subsections (b) and
(c) of section 5001 of Public Law 111-5.
``(B) In the case of the second or any succeeding fiscal
year for which this subsection applies to the State, the
Federal medical assistance percentage determined for the
preceding fiscal year under this subsection for the State,
increased by 25 percent of the number of percentage points by
which the Federal medical assistance percentage determined
for the State for the fiscal year without regard to this
subsection and subsection (y), is less than the Federal
medical assistance percentage determined for the State for
the preceding fiscal year under this subsection.
``(2) In this subsection, the term `disaster-recovery FMAP
adjustment State' means a State that is one of the 50 States
or the District of Columbia, for which, at any time during
the preceding 7 fiscal years, the President has declared a
major disaster under section 401 of the Robert T. Stafford
Disaster Relief and Emergency Assistance Act and determined
as a result of such disaster that every county or parish in
the State warrant individual and public assistance or public
assistance from the Federal Government under such Act and for
which--
``(A) in the case of the first fiscal year (or part of a
fiscal year) for which this subsection applies to the State,
the Federal medical assistance percentage determined for the
State for the fiscal year without regard to this subsection
and subsection (y), is less than the Federal medical
assistance percentage determined for the State for the
preceding fiscal year after the application of only
subsection (a) of section 5001 of Public Law 111-5 (if
applicable to the preceding fiscal year) and without regard
to this subsection, subsection (y), and subsections (b) and
(c) of section 5001 of Public Law 111-5, by at least 3
percentage points; and
``(B) in the case of the second or any succeeding fiscal
year for which this subsection applies to the State, the
Federal medical assistance percentage determined for the
State for the fiscal year without regard to this subsection
and subsection (y), is less than the Federal medical
assistance percentage determined for the State for the
preceding fiscal year under this subsection by at least 3
percentage points.
``(3) The Federal medical assistance percentage determined
for a disaster-recovery FMAP adjustment State under paragraph
(1) shall apply for purposes of this title (other than with
respect to disproportionate share hospital payments described
in section 1923 and payments under this title that are based
on the enhanced FMAP described in 2105(b)) and shall not
apply with respect to payments under title IV (other than
under part E of title IV) or payments under title XXI.''.
SEC. 2007. MEDICAID IMPROVEMENT FUND RESCISSION.
(a) Rescission.--Any amounts available to the Medicaid
Improvement Fund established under section 1941 of the Social
Security Act (42 U.S.C. 1396w-1) for any of fiscal years 2014
through 2018 that are available for expenditure from the Fund
and that are not so obligated as of the date of the enactment
of this Act are rescinded.
(b) Conforming Amendments.--Section 1941(b)(1) of the
Social Security Act (42 U.S.C. 1396w-1(b)(1)) is amended--
(1) in subparagraph (A), by striking ``$100,000,000'' and
inserting ``$0''; and
(2) in subparagraph (B), by striking ``$150,000,000'' and
inserting ``$0''.
Subtitle B--Enhanced Support for the Children's Health Insurance
Program
SEC. 2101. ADDITIONAL FEDERAL FINANCIAL PARTICIPATION FOR
CHIP.
(a) In General.--Section 2105(b) of the Social Security Act
(42 U.S.C. 1397ee(b)) is amended by adding at the end the
following: ``Notwithstanding the preceding sentence, during
the period that begins on October 1, 2013, and ends on
September 30, 2019, the enhanced FMAP determined for a State
for a fiscal year (or for any portion of a fiscal year
occurring during such period) shall be increased by 23
percentage points, but in no case shall exceed 100 percent.
The increase in the enhanced FMAP under the preceding
sentence shall not apply with respect to determining the
payment to a State under subsection (a)(1) for expenditures
described in subparagraph (D)(iv), paragraphs (8), (9), (11)
of subsection (c), or clause (4) of the first sentence of
section 1905(b).''.
(b) Maintenance of Effort.--
(1) In general.--Section 2105(d) of the Social Security Act
(42 U.S.C. 1397ee(d)) is amended by adding at the end the
following:
``(3) Continuation of eligibility standards for children
until october 1, 2019.--
``(A) In general.--During the period that begins on the
date of enactment of the Patient Protection and Affordable
Care Act and ends on September 30, 2019, a State shall not
have in effect eligibility standards, methodologies, or
procedures under its State child health plan (including any
waiver under such plan) for children (including children
provided medical assistance for which payment is made under
section 2105(a)(1)(A)) that are more restrictive than the
eligibility standards, methodologies, or procedures,
respectively, under such plan (or waiver) as in effect on the
date of enactment of that Act. The preceding sentence shall
not be construed as preventing a State during such period
from--
``(i) applying eligibility standards, methodologies, or
procedures for children under the State child health plan or
under any waiver of the plan that are less restrictive than
the eligibility standards, methodologies, or procedures,
respectively, for children under the plan or waiver that are
in effect on the date of enactment of such Act; or
``(ii) imposing a limitation described in section
2112(b)(7) for a fiscal year in order to limit expenditures
under the State child health plan to those for which Federal
financial participation is available under this section for
the fiscal year.
``(B) Assurance of exchange coverage for targeted low-
income children unable to be provided child health assistance
as a result of funding shortfalls.--In the event that
allotments provided under section 2104 are insufficient to
provide coverage to all children who are eligible to be
targeted low-income children under the State child health
plan under this title, a State shall establish procedures to
ensure that such children are provided coverage through an
Exchange established by the State under section 1311 of the
Patient Protection and Affordable Care Act.''.
(2) Conforming amendment to title xxi medicaid maintenance
of effort.--Section 2105(d)(1) of the Social Security Act (42
U.S.C. 1397ee(d)(1)) is amended by adding before the period
``, except as required under section 1902(e)(14)''.
(c) No Enrollment Bonus Payments for Children Enrolled
After Fiscal Year 2013.--Section 2105(a)(3)(F)(iii) of the
Social Security Act (42 U.S.C. 1397ee(a)(3)(F)(iii)) is
amended by inserting ``or any children enrolled on or after
October 1, 2013'' before the period.
(d) Income Eligibility Determined Using Modified Gross
Income.--
(1) State plan requirement.--Section 2102(b)(1)(B) of the
Social Security Act (42 U.S.C. 1397bb(b)(1)(B)) is amended--
(A) in clause (iii), by striking ``and'' after the
semicolon;
(B) in clause (iv), by striking the period and inserting
``; and''; and
(C) by adding at the end the following:
``(v) shall, beginning January 1, 2014, use modified gross
income and household income (as defined in section 36B(d)(2)
of the Internal Revenue Code of 1986) to determine
eligibility for child health assistance under the State child
health plan or under any waiver of such plan and for any
other purpose applicable under the plan or waiver for which a
determination of income is required, including with respect
to the imposition of premiums and cost-sharing, consistent
with section 1902(e)(14).''.
(2) Conforming amendment.--Section 2107(e)(1) of the Social
Security Act (42 U.S.C. 1397gg(e)(1)) is amended--
(A) by redesignating subparagraphs (E) through (L) as
subparagraphs (F) through (M), respectively; and
(B) by inserting after subparagraph (D), the following:
``(E) Section 1902(e)(14) (relating to income determined
using modified gross income and household income).''.
(e) Application of Streamlined Enrollment System.--Section
2107(e)(1) of the Social Security Act (42 U.S.C.
1397gg(e)(1)), as amended by subsection (d)(2), is amended by
adding at the end the following:
``(N) Section 1943(b) (relating to coordination with State
Exchanges and the State Medicaid agency).''.
[[Page H1965]]
(f) CHIP Eligibility for Children Ineligible for Medicaid
as a Result of Elimination of Disregards.--Notwithstanding
any other provision of law, a State shall treat any child who
is determined to be ineligible for medical assistance under
the State Medicaid plan or under a waiver of the plan as a
result of the elimination of the application of an income
disregard based on expense or type of income, as required
under section 1902(e)(14) of the Social Security Act (as
added by this Act), as a targeted low-income child under
section 2110(b) (unless the child is excluded under paragraph
(2) of that section) and shall provide child health
assistance to the child under the State child health plan
(whether implemented under title XIX or XXI, or both, of the
Social Security Act).
SEC. 2102. TECHNICAL CORRECTIONS.
(a) CHIPRA.--Effective as if included in the enactment of
the Children's Health Insurance Program Reauthorization Act
of 2009 (Public Law 111-3) (in this section referred to as
``CHIPRA''):
(1) Section 2104(m) of the Social Security Act, as added by
section 102 of CHIPRA, is amended--
(A) by redesignating paragraph (7) as paragraph (8); and
(B) by inserting after paragraph (6), the following:
``(7) Adjustment of fiscal year 2010 allotments to account
for changes in projected spending for certain previously
approved expansion programs.--For purposes of recalculating
the fiscal year 2010 allotment, in the case of one of the 50
States or the District of Columbia that has an approved State
plan amendment effective January 1, 2006, to provide child
health assistance through the provision of benefits under the
State plan under title XIX for children from birth through
age 5 whose family income does not exceed 200 percent of the
poverty line, the Secretary shall increase the allotment by
an amount that would be equal to the Federal share of
expenditures that would have been claimed at the enhanced
FMAP rate rather than the Federal medical assistance
percentage matching rate for such population.''.
(2) Section 605 of CHIPRA is amended by striking ``legal
residents'' and insert ``lawfully residing in the United
States''.
(3) Subclauses (I) and (II) of paragraph (3)(C)(i) of
section 2105(a) of the Social Security Act (42 U.S.C.
1397ee(a)(3)(ii)), as added by section 104 of CHIPRA, are
each amended by striking ``, respectively''.
(4) Section 2105(a)(3)(E)(ii) of the Social Security Act
(42 U.S.C. 1397ee(a)(3)(E)(ii)), as added by section 104 of
CHIPRA, is amended by striking subclause (IV).
(5) Section 2105(c)(9)(B) of the Social Security Act (42
U.S.C. 1397e(c)(9)(B)), as added by section 211(c)(1) of
CHIPRA, is amended by striking ``section 1903(a)(3)(F)'' and
inserting ``section 1903(a)(3)(G)''.
(6) Section 2109(b)(2)(B) of the Social Security Act (42
U.S.C. 1397ii(b)(2)(B)), as added by section 602 of CHIPRA,
is amended by striking ``the child population growth factor
under section 2104(m)(5)(B)'' and inserting ``a high-
performing State under section 2111(b)(3)(B)''.
(7) Section 2110(c)(9)(B)(v) of the Social Security Act (42
U.S.C. 1397jj(c)(9)(B)(v)), as added by section 505(b) of
CHIPRA, is amended by striking ``school or school system''
and inserting ``local educational agency (as defined under
section 9101 of the Elementary and Secondary Education Act of
1965''.
(8) Section 211(a)(1)(B) of CHIPRA is amended--
(A) by striking ``is amended'' and all that follows through
``adding'' and inserting ``is amended by adding''; and
(B) by redesignating the new subparagraph to be added by
such section to section 1903(a)(3) of the Social Security Act
as a new subparagraph (H).
(b) ARRA.--Effective as if included in the enactment of
section 5006(a) of division B of the American Recovery and
Reinvestment Act of 2009 (Public Law 111-5), the second
sentence of section 1916A(a)(1) of the Social Security Act
(42 U.S.C. 1396o-1(a)(1)) is amended by striking ``or (i)''
and inserting ``, (i), or (j)''.
Subtitle C--Medicaid and CHIP Enrollment Simplification
SEC. 2201. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH
STATE HEALTH INSURANCE EXCHANGES.
Title XIX of the Social Security Act (42 U.S.C. 1397aa et
seq.) is amended by adding at the end the following:
``SEC. 1943. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH
STATE HEALTH INSURANCE EXCHANGES.
``(a) Condition for Participation in Medicaid.--As a
condition of the State plan under this title and receipt of
any Federal financial assistance under section 1903(a) for
calendar quarters beginning after January 1, 2014, a State
shall ensure that the requirements of subsection (b) is met.
``(b) Enrollment Simplification and Coordination With State
Health Insurance Exchanges and Chip.--
``(1) In general.--A State shall establish procedures for--
``(A) enabling individuals, through an Internet website
that meets the requirements of paragraph (4), to apply for
medical assistance under the State plan or under a waiver of
the plan, to be enrolled in the State plan or waiver, to
renew their enrollment in the plan or waiver, and to consent
to enrollment or reenrollment in the State plan through
electronic signature;
``(B) enrolling, without any further determination by the
State and through such website, individuals who are
identified by an Exchange established by the State under
section 1311 of the Patient Protection and Affordable Care
Act as being eligible for--
``(i) medical assistance under the State plan or under a
waiver of the plan; or
``(ii) child health assistance under the State child health
plan under title XXI;
``(C) ensuring that individuals who apply for but are
determined to be ineligible for medical assistance under the
State plan or a waiver or ineligible for child health
assistance under the State child health plan under title XXI,
are screened for eligibility for enrollment in qualified
health plans offered through such an Exchange and, if
applicable, premium assistance for the purchase of a
qualified health plan under section 36B of the Internal
Revenue Code of 1986 (and, if applicable, advance payment of
such assistance under section 1412 of the Patient Protection
and Affordable Care Act), and, if eligible, enrolled in such
a plan without having to submit an additional or separate
application, and that such individuals receive information
regarding reduced cost-sharing for eligible individuals under
section 1402 of the Patient Protection and Affordable Care
Act, and any other assistance or subsidies available for
coverage obtained through the Exchange;
``(D) ensuring that the State agency responsible for
administering the State plan under this title (in this
section referred to as the `State Medicaid agency'), the
State agency responsible for administering the State child
health plan under title XXI (in this section referred to as
the `State CHIP agency') and an Exchange established by the
State under section 1311 of the Patient Protection and
Affordable Care Act utilize a secure electronic interface
sufficient to allow for a determination of an individual's
eligibility for such medical assistance, child health
assistance, or premium assistance, and enrollment in the
State plan under this title, title XXI, or a qualified health
plan, as appropriate;
``(E) coordinating, for individuals who are enrolled in the
State plan or under a waiver of the plan and who are also
enrolled in a qualified health plan offered through such an
Exchange, and for individuals who are enrolled in the State
child health plan under title XXI and who are also enrolled
in a qualified health plan, the provision of medical
assistance or child health assistance to such individuals
with the coverage provided under the qualified health plan in
which they are enrolled, including services described in
section 1905(a)(4)(B) (relating to early and periodic
screening, diagnostic, and treatment services defined in
section 1905(r)) and provided in accordance with the
requirements of section 1902(a)(43); and
``(F) conducting outreach to and enrolling vulnerable and
underserved populations eligible for medical assistance under
this title XIX or for child health assistance under title
XXI, including children, unaccompanied homeless youth,
children and youth with special health care needs, pregnant
women, racial and ethnic minorities, rural populations,
victims of abuse or trauma, individuals with mental health or
substance-related disorders, and individuals with HIV/AIDS.
``(2) Agreements with state health insurance exchanges.--
The State Medicaid agency and the State CHIP agency may enter
into an agreement with an Exchange established by the State
under section 1311 of the Patient Protection and Affordable
Care Act under which the State Medicaid agency or State CHIP
agency may determine whether a State resident is eligible for
premium assistance for the purchase of a qualified health
plan under section 36B of the Internal Revenue Code of 1986
(and, if applicable, advance payment of such assistance under
section 1412 of the Patient Protection and Affordable Care
Act), so long as the agreement meets such conditions and
requirements as the Secretary of the Treasury may prescribe
to reduce administrative costs and the likelihood of
eligibility errors and disruptions in coverage.
``(3) Streamlined enrollment system.--The State Medicaid
agency and State CHIP agency shall participate in and comply
with the requirements for the system established under
section 1413 of the Patient Protection and Affordable Care
Act (relating to streamlined procedures for enrollment
through an Exchange, Medicaid, and CHIP).
``(4) Enrollment website requirements.--The procedures
established by State under paragraph (1) shall include
establishing and having in operation, not later than January
1, 2014, an Internet website that is linked to any website of
an Exchange established by the State under section 1311 of
the Patient Protection and Affordable Care Act and to the
State CHIP agency (if different from the State Medicaid
agency) and allows an individual who is eligible for medical
assistance under the State plan or under a waiver of the plan
and who is eligible to receive premium credit assistance for
the purchase of a qualified health plan under section 36B of
the Internal Revenue Code of 1986 to compare the benefits,
premiums, and cost-sharing applicable to the individual under
the State plan or waiver with the benefits, premiums, and
cost-sharing available to the individual under a qualified
health plan offered through such an Exchange, including, in
the case of a child, the coverage that would be provided for
the child through the State plan or waiver with the coverage
that would be provided to the child through enrollment in
family coverage under that plan and as supplemental coverage
by the State under the State plan or waiver.
``(5) Continued need for assessment for home and community-
based services.--Nothing in paragraph (1) shall limit or
modify the requirement that the State assess an individual
for purposes of providing home and community-based services
under the State plan or under any waiver of such plan for
individuals described in subsection (a)(10)(A)(ii)(VI).''.
[[Page H1966]]
SEC. 2202. PERMITTING HOSPITALS TO MAKE PRESUMPTIVE
ELIGIBILITY DETERMINATIONS FOR ALL MEDICAID
ELIGIBLE POPULATIONS.
(a) In General.--Section 1902(a)(47) of the Social Security
Act (42 U.S.C. 1396a(a)(47)) is amended--
(1) by striking ``at the option of the State, provide'' and
inserting ``provide--
``(A) at the option of the State,'';
(2) by inserting ``and'' after the semicolon; and
(3) by adding at the end the following:
``(B) that any hospital that is a participating provider
under the State plan may elect to be a qualified entity for
purposes of determining, on the basis of preliminary
information, whether any individual is eligible for medical
assistance under the State plan or under a waiver of the plan
for purposes of providing the individual with medical
assistance during a presumptive eligibility period, in the
same manner, and subject to the same requirements, as apply
to the State options with respect to populations described in
section 1920, 1920A, or 1920B (but without regard to whether
the State has elected to provide for a presumptive
eligibility period under any such sections), subject to such
guidance as the Secretary shall establish;''.
(b) Conforming Amendment.--Section 1903(u)(1)(D)(v) of such
Act (42 U.S.C. 1396b(u)(1)(D)v)) is amended--
(1) by striking ``or for'' and inserting ``for''; and
(2) by inserting before the period at the end the
following: ``, or for medical assistance provided to an
individual during a presumptive eligibility period resulting
from a determination of presumptive eligibility made by a
hospital that elects under section 1902(a)(47)(B) to be a
qualified entity for such purpose''.
(c) Effective Date.--The amendments made by this section
take effect on January 1, 2014, and apply to services
furnished on or after that date.
Subtitle D--Improvements to Medicaid Services
SEC. 2301. COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES.
(a) In General.--Section 1905 of the Social Security Act
(42 U.S.C. 1396d), is amended--
(1) in subsection (a)--
(A) in paragraph (27), by striking ``and'' at the end;
(B) by redesignating paragraph (28) as paragraph (29); and
(C) by inserting after paragraph (27) the following new
paragraph:
``(28) freestanding birth center services (as defined in
subsection (l)(3)(A)) and other ambulatory services that are
offered by a freestanding birth center (as defined in
subsection (l)(3)(B)) and that are otherwise included in the
plan; and''; and
(2) in subsection (l), by adding at the end the following
new paragraph:
``(3)(A) The term `freestanding birth center services'
means services furnished to an individual at a freestanding
birth center (as defined in subparagraph (B)) at such center.
``(B) The term `freestanding birth center' means a health
facility--
``(i) that is not a hospital;
``(ii) where childbirth is planned to occur away from the
pregnant woman's residence;
``(iii) that is licensed or otherwise approved by the State
to provide prenatal labor and delivery or postpartum care and
other ambulatory services that are included in the plan; and
``(iv) that complies with such other requirements relating
to the health and safety of individuals furnished services by
the facility as the State shall establish.
``(C) A State shall provide separate payments to providers
administering prenatal labor and delivery or postpartum care
in a freestanding birth center (as defined in subparagraph
(B)), such as nurse midwives and other providers of services
such as birth attendants recognized under State law, as
determined appropriate by the Secretary. For purposes of the
preceding sentence, the term `birth attendant' means an
individual who is recognized or registered by the State
involved to provide health care at childbirth and who
provides such care within the scope of practice under which
the individual is legally authorized to perform such care
under State law (or the State regulatory mechanism provided
by State law), regardless of whether the individual is under
the supervision of, or associated with, a physician or other
health care provider. Nothing in this subparagraph shall be
construed as changing State law requirements applicable to a
birth attendant.''.
(b) Conforming Amendment.--Section 1902(a)(10)(A) of the
Social Security Act (42 U.S.C. 1396a(a)(10)(A)), is amended
in the matter preceding clause (i) by striking ``and (21)''
and inserting ``, (21), and (28)''.
(c) Effective Date.--
(1) In general.--Except as provided in paragraph (2), the
amendments made by this section shall take effect on the date
of the enactment of this Act and shall apply to services
furnished on or after such date.
(2) Exception if state legislation required.--In the case
of a State plan for medical assistance under title XIX of the
Social Security Act which the Secretary of Health and Human
Services determines requires State legislation (other than
legislation appropriating funds) in order for the plan to
meet the additional requirement imposed by the amendments
made by this section, the State plan shall not be regarded as
failing to comply with the requirements of such title solely
on the basis of its failure to meet this additional
requirement before the first day of the first calendar
quarter beginning after the close of the first regular
session of the State legislature that begins after the date
of the enactment of this Act. For purposes of the previous
sentence, in the case of a State that has a 2-year
legislative session, each year of such session shall be
deemed to be a separate regular session of the State
legislature.
SEC. 2302. CONCURRENT CARE FOR CHILDREN.
(a) In General.--Section 1905(o)(1) of the Social Security
Act (42 U.S.C. 1396d(o)(1)) is amended--
(1) in subparagraph (A), by striking ``subparagraph (B)''
and inserting ``subparagraphs (B) and (C)''; and
(2) by adding at the end the following new subparagraph:
``(C) A voluntary election to have payment made for hospice
care for a child (as defined by the State) shall not
constitute a waiver of any rights of the child to be provided
with, or to have payment made under this title for, services
that are related to the treatment of the child's condition
for which a diagnosis of terminal illness has been made.''.
(b) Application to CHIP.--Section 2110(a)(23) of the Social
Security Act (42 U.S.C. 1397jj(a)(23)) is amended by
inserting ``(concurrent, in the case of an individual who is
a child, with care related to the treatment of the child's
condition with respect to which a diagnosis of terminal
illness has been made'' after ``hospice care''.
SEC. 2303. STATE ELIGIBILITY OPTION FOR FAMILY PLANNING
SERVICES.
(a) Coverage as Optional Categorically Needy Group.--
(1) In general.--Section 1902(a)(10)(A)(ii) of the Social
Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by
section 2001(e), is amended--
(A) in subclause (XIX), by striking ``or'' at the end;
(B) in subclause (XX), by adding ``or'' at the end; and
(C) by adding at the end the following new subclause:
``(XXI) who are described in subsection (ii) (relating to
individuals who meet certain income standards);''.
(2) Group described.--Section 1902 of such Act (42 U.S.C.
1396a), as amended by section 2001(d), is amended by adding
at the end the following new subsection:
``(ii)(1) Individuals described in this subsection are
individuals--
``(A) whose income does not exceed an income eligibility
level established by the State that does not exceed the
highest income eligibility level established under the State
plan under this title (or under its State child health plan
under title XXI) for pregnant women; and
``(B) who are not pregnant.
``(2) At the option of a State, individuals described in
this subsection may include individuals who, had individuals
applied on or before January 1, 2007, would have been made
eligible pursuant to the standards and processes imposed by
that State for benefits described in clause (XV) of the
matter following subparagraph (G) of section subsection
(a)(10) pursuant to a waiver granted under section 1115.
``(3) At the option of a State, for purposes of subsection
(a)(17)(B), in determining eligibility for services under
this subsection, the State may consider only the income of
the applicant or recipient.''.
(3) Limitation on benefits.--Section 1902(a)(10) of the
Social Security Act (42 U.S.C. 1396a(a)(10)), as amended by
section 2001(a)(5)(A), is amended in the matter following
subparagraph (G)--
(A) by striking ``and (XV)'' and inserting ``(XV)''; and
(B) by inserting ``, and (XVI) the medical assistance made
available to an individual described in subsection (ii) shall
be limited to family planning services and supplies described
in section 1905(a)(4)(C) including medical diagnosis and
treatment services that are provided pursuant to a family
planning service in a family planning setting'' before the
semicolon.
(4) Conforming amendments.--
(A) Section 1905(a) of the Social Security Act (42 U.S.C.
1396d(a)), as amended by section 2001(e)(2)(A), is amended in
the matter preceding paragraph (1)--
(i) in clause (xiv), by striking ``or'' at the end;
(ii) in clause (xv), by adding ``or'' at the end; and
(iii) by inserting after clause (xv) the following:
``(xvi) individuals described in section 1902(ii),''.
(B) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)),
as amended by section 2001(e)(2)(B), is amended by inserting
``1902(a)(10)(A)(ii)(XXI),'' after
``1902(a)(10)(A)(ii)(XX),''.
(b) Presumptive Eligibility.--
(1) In general.--Title XIX of the Social Security Act (42
U.S.C. 1396 et seq.) is amended by inserting after section
1920B the following:
``presumptive eligibility for family planning services
``Sec. 1920C. (a) State Option.--State plan approved under
section 1902 may provide for making medical assistance
available to an individual described in section 1902(ii)
(relating to individuals who meet certain income eligibility
standard) during a presumptive eligibility period. In the
case of an individual described in section 1902(ii), such
medical assistance shall be limited to family planning
services and supplies described in 1905(a)(4)(C) and, at the
State's option, medical diagnosis and treatment services that
are provided in conjunction with a family planning service in
a family planning setting.
``(b) Definitions.--For purposes of this section:
``(1) Presumptive eligibility period.--The term
`presumptive eligibility period' means, with respect to an
individual described in subsection (a), the period that--
``(A) begins with the date on which a qualified entity
determines, on the basis of preliminary information, that the
individual is described in section 1902(ii); and
[[Page H1967]]
``(B) ends with (and includes) the earlier of--
``(i) the day on which a determination is made with respect
to the eligibility of such individual for services under the
State plan; or
``(ii) in the case of such an individual who does not file
an application by the last day of the month following the
month during which the entity makes the determination
referred to in subparagraph (A), such last day.
``(2) Qualified entity.--
``(A) In general.--Subject to subparagraph (B), the term
`qualified entity' means any entity that--
``(i) is eligible for payments under a State plan approved
under this title; and
``(ii) is determined by the State agency to be capable of
making determinations of the type described in paragraph
(1)(A).
``(B) Rule of construction.--Nothing in this paragraph
shall be construed as preventing a State from limiting the
classes of entities that may become qualified entities in
order to prevent fraud and abuse.
``(c) Administration.--
``(1) In general.--The State agency shall provide qualified
entities with--
``(A) such forms as are necessary for an application to be
made by an individual described in subsection (a) for medical
assistance under the State plan; and
``(B) information on how to assist such individuals in
completing and filing such forms.
``(2) Notification requirements.--A qualified entity that
determines under subsection (b)(1)(A) that an individual
described in subsection (a) is presumptively eligible for
medical assistance under a State plan shall--
``(A) notify the State agency of the determination within 5
working days after the date on which determination is made;
and
``(B) inform such individual at the time the determination
is made that an application for medical assistance is
required to be made by not later than the last day of the
month following the month during which the determination is
made.
``(3) Application for medical assistance.--In the case of
an individual described in subsection (a) who is determined
by a qualified entity to be presumptively eligible for
medical assistance under a State plan, the individual shall
apply for medical assistance by not later than the last day
of the month following the month during which the
determination is made.
``(d) Payment.--Notwithstanding any other provision of law,
medical assistance that--
``(1) is furnished to an individual described in subsection
(a)--
``(A) during a presumptive eligibility period; and
``(B) by a entity that is eligible for payments under the
State plan; and
``(2) is included in the care and services covered by the
State plan,
shall be treated as medical assistance provided by such plan
for purposes of clause (4) of the first sentence of section
1905(b).''.
(2) Conforming amendments.--
(A) Section 1902(a)(47) of the Social Security Act (42
U.S.C. 1396a(a)(47)), as amended by section 2202(a), is
amended--
(i) in subparagraph (A), by inserting before the semicolon
at the end the following: ``and provide for making medical
assistance available to individuals described in subsection
(a) of section 1920C during a presumptive eligibility period
in accordance with such section''; and
(ii) in subparagraph (B), by striking ``or 1920B'' and
inserting ``1920B, or 1920C''.
(B) Section 1903(u)(1)(D)(v) of such Act (42 U.S.C.
1396b(u)(1)(D)(v)), as amended by section 2202(b), is amended
by inserting ``or for medical assistance provided to an
individual described in subsection (a) of section 1920C
during a presumptive eligibility period under such section,''
after ``1920B during a presumptive eligibility period under
such section,''.
(c) Clarification of Coverage of Family Planning Services
and Supplies.--Section 1937(b) of the Social Security Act (42
U.S.C. 1396u-7(b)), as amended by section 2001(c), is amended
by adding at the end the following:
``(7) Coverage of family planning services and supplies.--
Notwithstanding the previous provisions of this section, a
State may not provide for medical assistance through
enrollment of an individual with benchmark coverage or
benchmark-equivalent coverage under this section unless such
coverage includes for any individual described in section
1905(a)(4)(C), medical assistance for family planning
services and supplies in accordance with such section.''.
(d) Effective Date.--The amendments made by this section
take effect on the date of the enactment of this Act and
shall apply to items and services furnished on or after such
date.
SEC. 2304. CLARIFICATION OF DEFINITION OF MEDICAL ASSISTANCE.
Section 1905(a) of the Social Security Act (42 U.S.C.
1396d(a)) is amended by inserting ``or the care and services
themselves, or both'' before ``(if provided in or after''.
Subtitle E--New Options for States to Provide Long-Term Services and
Supports
SEC. 2401. COMMUNITY FIRST CHOICE OPTION.
Section 1915 of the Social Security Act (42 U.S.C. 1396n)
is amended by adding at the end the following:
``(k) State Plan Option To Provide Home and Community-based
Attendant Services and Supports.--
``(1) In general.--Subject to the succeeding provisions of
this subsection, beginning October 1, 2010, a State may
provide through a State plan amendment for the provision of
medical assistance for home and community-based attendant
services and supports for individuals who are eligible for
medical assistance under the State plan whose income does not
exceed 150 percent of the poverty line (as defined in section
2110(c)(5)) or, if greater, the income level applicable for
an individual who has been determined to require an
institutional level of care to be eligible for nursing
facility services under the State plan and with respect to
whom there has been a determination that, but for the
provision of such services, the individuals would require the
level of care provided in a hospital, a nursing facility, an
intermediate care facility for the mentally retarded, or an
institution for mental diseases, the cost of which could be
reimbursed under the State plan, but only if the individual
chooses to receive such home and community-based attendant
services and supports, and only if the State meets the
following requirements:
``(A) Availability.--The State shall make available home
and community-based attendant services and supports to
eligible individuals, as needed, to assist in accomplishing
activities of daily living, instrumental activities of daily
living, and health-related tasks through hands-on assistance,
supervision, or cueing--
``(i) under a person-centered plan of services and supports
that is based on an assessment of functional need and that is
agreed to in writing by the individual or, as appropriate,
the individual's representative;
``(ii) in a home or community setting, which does not
include a nursing facility, institution for mental diseases,
or an intermediate care facility for the mentally retarded;
``(iii) under an agency-provider model or other model (as
defined in paragraph (6)(C )); and
``(iv) the furnishing of which--
``(I) is selected, managed, and dismissed by the
individual, or, as appropriate, with assistance from the
individual's representative;
``(II) is controlled, to the maximum extent possible, by
the individual or where appropriate, the individual's
representative, regardless of who may act as the employer of
record; and
``(III) provided by an individual who is qualified to
provide such services, including family members (as defined
by the Secretary).
``(B) Included services and supports.--In addition to
assistance in accomplishing activities of daily living,
instrumental activities of daily living, and health related
tasks, the home and community-based attendant services and
supports made available include--
``(i) the acquisition, maintenance, and enhancement of
skills necessary for the individual to accomplish activities
of daily living, instrumental activities of daily living, and
health related tasks;
``(ii) back-up systems or mechanisms (such as the use of
beepers or other electronic devices) to ensure continuity of
services and supports; and
``(iii) voluntary training on how to select, manage, and
dismiss attendants.
``(C) Excluded services and supports.--Subject to
subparagraph (D), the home and community-based attendant
services and supports made available do not include--
``(i) room and board costs for the individual;
``(ii) special education and related services provided
under the Individuals with Disabilities Education Act and
vocational rehabilitation services provided under the
Rehabilitation Act of 1973;
``(iii) assistive technology devices and assistive
technology services other than those under (1)(B)(ii);
``(iv) medical supplies and equipment; or
``(v) home modifications.
``(D) Permissible services and supports.--The home and
community-based attendant services and supports may include--
``(i) expenditures for transition costs such as rent and
utility deposits, first month's rent and utilities, bedding,
basic kitchen supplies, and other necessities required for an
individual to make the transition from a nursing facility,
institution for mental diseases, or intermediate care
facility for the mentally retarded to a community-based home
setting where the individual resides; and
``(ii) expenditures relating to a need identified in an
individual's person-centered plan of services that increase
independence or substitute for human assistance, to the
extent that expenditures would otherwise be made for the
human assistance.
``(2) Increased federal financial participation.--For
purposes of payments to a State under section 1903(a)(1),
with respect to amounts expended by the State to provide
medical assistance under the State plan for home and
community-based attendant services and supports to eligible
individuals in accordance with this subsection during a
fiscal year quarter occurring during the period described in
paragraph (1), the Federal medical assistance percentage
applicable to the State (as determined under section 1905(b))
shall be increased by 6 percentage points.
``(3) State requirements.--In order for a State plan
amendment to be approved under this subsection, the State
shall--
``(A) develop and implement such amendment in collaboration
with a Development and Implementation Council established by
the State that includes a majority of members with
disabilities, elderly individuals, and their representatives
and consults and collaborates with such individuals;
``(B) provide consumer controlled home and community-based
attendant services and supports to individuals on a statewide
basis, in a manner that provides such services and supports
in the most integrated setting appropriate to the
individual's needs, and without regard to the individual's
age, type or nature of disability, severity of disability, or
the form of home and community-based attendant services and
supports that the individual requires in order to lead an
independent life;
``(C) with respect to expenditures during the first full
fiscal year in which the State plan amendment is implemented,
maintain or exceed the level of State expenditures for
medical assistance that is provided under section 1905(a),
[[Page H1968]]
section 1915, section 1115, or otherwise to individuals with
disabilities or elderly individuals attributable to the
preceding fiscal year;
``(D) establish and maintain a comprehensive, continuous
quality assurance system with respect to community- based
attendant services and supports that--
``(i) includes standards for agency-based and other
delivery models with respect to training, appeals for denials
and reconsideration procedures of an individual plan, and
other factors as determined by the Secretary;
``(ii) incorporates feedback from consumers and their
representatives, disability organizations, providers,
families of disabled or elderly individuals, members of the
community, and others and maximizes consumer independence and
consumer control;
``(iii) monitors the health and well-being of each
individual who receives home and community-based attendant
services and supports, including a process for the mandatory
reporting, investigation, and resolution of allegations of
neglect, abuse, or exploitation in connection with the
provision of such services and supports; and
``(iv) provides information about the provisions of the
quality assurance required under clauses (i) through (iii) to
each individual receiving such services; and
``(E) collect and report information, as determined
necessary by the Secretary, for the purposes of approving the
State plan amendment, providing Federal oversight, and
conducting an evaluation under paragraph (5)(A), including
data regarding how the State provides home and community-
based attendant services and supports and other home and
community-based services, the cost of such services and
supports, and how the State provides individuals with
disabilities who otherwise qualify for institutional care
under the State plan or under a waiver the choice to instead
receive home and community-based services in lieu of
institutional care.
``(4) Compliance with certain laws.--A State shall ensure
that, regardless of whether the State uses an agency-provider
model or other models to provide home and community-based
attendant services and supports under a State plan amendment
under this subsection, such services and supports are
provided in accordance with the requirements of the Fair
Labor Standards Act of 1938 and applicable Federal and State
laws regarding--
``(A) withholding and payment of Federal and State income
and payroll taxes;
``(B) the provision of unemployment and workers
compensation insurance;
``(C) maintenance of general liability insurance; and
``(D) occupational health and safety.
``(5) Evaluation, data collection, and report to
congress.--
``(A) Evaluation.--The Secretary shall conduct an
evaluation of the provision of home and community-based
attendant services and supports under this subsection in
order to determine the effectiveness of the provision of such
services and supports in allowing the individuals receiving
such services and supports to lead an independent life to the
maximum extent possible; the impact on the physical and
emotional health of the individuals who receive such
services; and an comparative analysis of the costs of
services provided under the State plan amendment under this
subsection and those provided under institutional care in a
nursing facility, institution for mental diseases, or an
intermediate care facility for the mentally retarded.
``(B) Data collection.--The State shall provide the
Secretary with the following information regarding the
provision of home and community-based attendant services and
supports under this subsection for each fiscal year for which
such services and supports are provided:
``(i) The number of individuals who are estimated to
receive home and community-based attendant services and
supports under this subsection during the fiscal year.
``(ii) The number of individuals that received such
services and supports during the preceding fiscal year.
``(iii) The specific number of individuals served by type
of disability, age, gender, education level, and employment
status.
``(iv) Whether the specific individuals have been
previously served under any other home and community based
services program under the State plan or under a waiver.
``(C) Reports.--Not later than--
``(i) December 31, 2013, the Secretary shall submit to
Congress and make available to the public an interim report
on the findings of the evaluation under subparagraph (A); and
``(ii) December 31, 2015, the Secretary shall submit to
Congress and make available to the public a final report on
the findings of the evaluation under subparagraph (A).
``(6) Definitions.--In this subsection:
``(A) Activities of daily living.--The term `activities of
daily living' includes tasks such as eating, toileting,
grooming, dressing, bathing, and transferring.
``(B) Consumer controlled.--The term `consumer controlled'
means a method of selecting and providing services and
supports that allow the individual, or where appropriate, the
individual's representative, maximum control of the home and
community-based attendant services and supports, regardless
of who acts as the employer of record.
``(C) Delivery models.--
``(i) Agency-provider model.--The term `agency-provider
model' means, with respect to the provision of home and
community-based attendant services and supports for an
individual, subject to paragraph (4), a method of providing
consumer controlled services and supports under which
entities contract for the provision of such services and
supports.
``(ii) Other models.--The term `other models' means,
subject to paragraph (4), methods, other than an agency-
provider model, for the provision of consumer controlled
services and supports. Such models may include the provision
of vouchers, direct cash payments, or use of a fiscal agent
to assist in obtaining services.
``(D) Health-related tasks.--The term `health-related
tasks' means specific tasks related to the needs of an
individual, which can be delegated or assigned by licensed
health-care professionals under State law to be performed by
an attendant.
``(E) Individual's representative.--The term `individual's
representative' means a parent, family member, guardian,
advocate, or other authorized representative of an
individual.
``(F) Instrumental activities of daily living.--The term
`instrumental activities of daily living' includes (but is
not limited to) meal planning and preparation, managing
finances, shopping for food, clothing, and other essential
items, performing essential household chores, communicating
by phone or other media, and traveling around and
participating in the community.''.
SEC. 2402. REMOVAL OF BARRIERS TO PROVIDING HOME AND
COMMUNITY-BASED SERVICES.
(a) Oversight and Assessment of the Administration of Home
and Community-based Services.--The Secretary of Health and
Human Services shall promulgate regulations to ensure that
all States develop service systems that are designed to--
(1) allocate resources for services in a manner that is
responsive to the changing needs and choices of beneficiaries
receiving non-institutionally-based long-term services and
supports (including such services and supports that are
provided under programs other the State Medicaid program),
and that provides strategies for beneficiaries receiving such
services to maximize their independence, including through
the use of client-employed providers;
(2) provide the support and coordination needed for a
beneficiary in need of such services (and their family
caregivers or representative, if applicable) to design an
individualized, self-directed, community-supported life; and
(3) improve coordination among, and the regulation of, all
providers of such services under federally and State-funded
programs in order to--
(A) achieve a more consistent administration of policies
and procedures across programs in relation to the provision
of such services; and
(B) oversee and monitor all service system functions to
assure--
(i) coordination of, and effectiveness of, eligibility
determinations and individual assessments;
(ii) development and service monitoring of a complaint
system, a management system, a system to qualify and monitor
providers, and systems for role-setting and individual budget
determinations; and
(iii) an adequate number of qualified direct care workers
to provide self-directed personal assistance services.
(b) Additional State Options.--Section 1915(i) of the
Social Security Act (42 U.S.C. 1396n(i)) is amended by adding
at the end the following new paragraphs:
``(6) State option to provide home and community-based
services to individuals eligible for services under a
waiver.--
``(A) In general.--A State that provides home and
community-based services in accordance with this subsection
to individuals who satisfy the needs-based criteria for the
receipt of such services established under paragraph (1)(A)
may, in addition to continuing to provide such services to
such individuals, elect to provide home and community-based
services in accordance with the requirements of this
paragraph to individuals who are eligible for home and
community-based services under a waiver approved for the
State under subsection (c), (d), or (e) or under section 1115
to provide such services, but only for those individuals
whose income does not exceed 300 percent of the supplemental
security income benefit rate established by section
1611(b)(1).
``(B) Application of same requirements for individuals
satisfying needs-based criteria.--Subject to subparagraph
(C), a State shall provide home and community-based services
to individuals under this paragraph in the same manner and
subject to the same requirements as apply under the other
paragraphs of this subsection to the provision of home and
community-based services to individuals who satisfy the
needs-based criteria established under paragraph (1)(A).
``(C) Authority to offer different type, amount, duration,
or scope of home and community-based services.--A State may
offer home and community-based services to individuals under
this paragraph that differ in type, amount, duration, or
scope from the home and community-based services offered for
individuals who satisfy the needs-based criteria established
under paragraph (1)(A), so long as such services are within
the scope of services described in paragraph (4)(B) of
subsection (c) for which the Secretary has the authority to
approve a waiver and do not include room or board.
``(7) State option to offer home and community-based
services to specific, targeted populations.--
``(A) In general.--A State may elect in a State plan
amendment under this subsection to target the provision of
home and community-based services under this subsection to
specific populations and to differ the type, amount,
duration, or scope of such services to such specific
populations.
``(B) 5-year term.--
``(i) In general.--An election by a State under this
paragraph shall be for a period of 5 years.
``(ii) Phase-in of services and eligibility permitted
during initial 5-year period.--A State making an election
under this paragraph
[[Page H1969]]
may, during the first 5-year period for which the election is
made, phase-in the enrollment of eligible individuals, or the
provision of services to such individuals, or both, so long
as all eligible individuals in the State for such services
are enrolled, and all such services are provided, before the
end of the initial 5-year period.
``(C) Renewal.--An election by a State under this paragraph
may be renewed for additional 5-year terms if the Secretary
determines, prior to beginning of each such renewal period,
that the State has--
``(i) adhered to the requirements of this subsection and
paragraph in providing services under such an election; and
``(ii) met the State's objectives with respect to quality
improvement and beneficiary outcomes.''.
(c) Removal of Limitation on Scope of Services.--Paragraph
(1) of section 1915(i) of the Social Security Act (42 U.S.C.
1396n(i)), as amended by subsection (a), is amended by
striking ``or such other services requested by the State as
the Secretary may approve''.
(d) Optional Eligibility Category To Provide Full Medicaid
Benefits to Individuals Receiving Home and Community-based
Services Under a State Plan Amendment.--
(1) In general.--Section 1902(a)(10)(A)(ii) of the Social
Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by
section 2304(a)(1), is amended--
(A) in subclause (XX), by striking ``or'' at the end;
(B) in subclause (XXI), by adding ``or'' at the end; and
(C) by inserting after subclause (XXI), the following new
subclause:
``(XXII) who are eligible for home and community-based
services under needs-based criteria established under
paragraph (1)(A) of section 1915(i), or who are eligible for
home and community-based services under paragraph (6) of such
section, and who will receive home and community-based
services pursuant to a State plan amendment under such
subsection;''.
(2) Conforming amendments.--
(A) Section 1903(f)(4) of the Social Security Act (42
U.S.C. 1396b(f)(4)), as amended by section 2304(a)(4)(B), is
amended in the matter preceding subparagraph (A), by
inserting ``1902(a)(10)(A)(ii)(XXII),'' after
``1902(a)(10)(A)(ii)(XXI),''.
(B) Section 1905(a) of the Social Security Act (42 U.S.C.
1396d(a)), as so amended, is amended in the matter preceding
paragraph (1)--
(i) in clause (xv), by striking ``or'' at the end;
(ii) in clause (xvi), by adding ``or'' at the end; and
(iii) by inserting after clause (xvi) the following new
clause:
``(xvii) individuals who are eligible for home and
community-based services under needs-based criteria
established under paragraph (1)(A) of section 1915(i), or who
are eligible for home and community-based services under
paragraph (6) of such section, and who will receive home and
community-based services pursuant to a State plan amendment
under such subsection,''.
(e) Elimination of Option To Limit Number of Eligible
Individuals or Length of Period for Grandfathered Individuals
if Eligibility Criteria Is Modified.--Paragraph (1) of
section 1915(i) of such Act (42 U.S.C. 1396n(i)) is amended--
(1) by striking subparagraph (C) and inserting the
following:
``(C) Projection of number of individuals to be provided
home and community-based services.--The State submits to the
Secretary, in such form and manner, and upon such frequency
as the Secretary shall specify, the projected number of
individuals to be provided home and community-based
services.''; and
(2) in subclause (II) of subparagraph (D)(ii), by striking
``to be eligible for such services for a period of at least
12 months beginning on the date the individual first received
medical assistance for such services'' and inserting ``to
continue to be eligible for such services after the effective
date of the modification and until such time as the
individual no longer meets the standard for receipt of such
services under such pre-modified criteria''.
(f) Elimination of Option To Waive Statewideness; Addition
of Option To Waive Comparability.--Paragraph (3) of section
1915(i) of such Act (42 U.S.C. 1396n(3)) is amended by
striking ``1902(a)(1) (relating to statewideness)'' and
inserting ``1902(a)(10)(B) (relating to comparability)''.
(g) Effective Date.--The amendments made by subsections (b)
through (f) take effect on the first day of the first fiscal
year quarter that begins after the date of enactment of this
Act.
SEC. 2403. MONEY FOLLOWS THE PERSON REBALANCING
DEMONSTRATION.
(a) Extension of Demonstration.--
(1) In general.--Section 6071(h) of the Deficit Reduction
Act of 2005 (42 U.S.C. 1396a note) is amended--
(A) in paragraph (1)(E), by striking ``fiscal year 2011''
and inserting ``each of fiscal years 2011 through 2016''; and
(B) in paragraph (2), by striking ``2011'' and inserting
``2016''.
(2) Evaluation.--Paragraphs (2) and (3) of section 6071(g)
of such Act is amended are each amended by striking ``2011''
and inserting ``2016''.
(b) Reduction of Institutional Residency Period.--
(1) In general.--Section 6071(b)(2) of the Deficit
Reduction Act of 2005 (42 U.S.C. 1396a note) is amended--
(A) in subparagraph (A)(i), by striking ``, for a period of
not less than 6 months or for such longer minimum period, not
to exceed 2 years, as may be specified by the State'' and
inserting ``for a period of not less than 90 consecutive
days''; and
(B) by adding at the end the following:
``Any days that an individual resides in an institution on
the basis of having been admitted solely for purposes of
receiving short-term rehabilitative services for a period for
which payment for such services is limited under title XVIII
shall not be taken into account for purposes of determining
the 90-day period required under subparagraph (A)(i).''.
(2) Effective date.--The amendments made by this subsection
take effect 30 days after the date of enactment of this Act.
SEC. 2404. PROTECTION FOR RECIPIENTS OF HOME AND COMMUNITY-
BASED SERVICES AGAINST SPOUSAL IMPOVERISHMENT.
During the 5-year period that begins on January 1, 2014,
section 1924(h)(1)(A) of the Social Security Act (42 U.S.C.
1396r-5(h)(1)(A)) shall be applied as though ``is eligible
for medical assistance for home and community-based services
provided under subsection (c), (d), or (i) of section 1915,
under a waiver approved under section 1115, or who is
eligible for such medical assistance by reason of being
determined eligible under section 1902(a)(10)(C) or by reason
of section 1902(f) or otherwise on the basis of a reduction
of income based on costs incurred for medical or other
remedial care, or who is eligible for medical assistance for
home and community-based attendant services and supports
under section 1915(k)'' were substituted in such section for
``(at the option of the State) is described in section
1902(a)(10)(A)(ii)(VI)''.
SEC. 2405. FUNDING TO EXPAND STATE AGING AND DISABILITY
RESOURCE CENTERS.
Out of any funds in the Treasury not otherwise
appropriated, there is appropriated to the Secretary of
Health and Human Services, acting through the Assistant
Secretary for Aging, $10,000,000 for each of fiscal years
2010 through 2014, to carry out subsections (a)(20)(B)(iii)
and (b)(8) of section 202 of the Older Americans Act of 1965
(42 U.S.C. 3012).
SEC. 2406. SENSE OF THE SENATE REGARDING LONG-TERM CARE.
(a) Findings.--The Senate makes the following findings:
(1) Nearly 2 decades have passed since Congress seriously
considered long-term care reform. The United States
Bipartisan Commission on Comprehensive Health Care, also know
as the ``Pepper Commission'', released its ``Call for
Action'' blueprint for health reform in September 1990. In
the 20 years since those recommendations were made, Congress
has never acted on the report.
(2) In 1999, under the United States Supreme Court's
decision in Olmstead v. L.C., 527 U.S. 581 (1999),
individuals with disabilities have the right to choose to
receive their long-term services and supports in the
community, rather than in an institutional setting.
(3) Despite the Pepper Commission and Olmstead decision,
the long-term care provided to our Nation's elderly and
disabled has not improved. In fact, for many, it has gotten
far worse.
(4) In 2007, 69 percent of Medicaid long-term care spending
for elderly individuals and adults with physical disabilities
paid for institutional services. Only 6 states spent 50
percent or more of their Medicaid long-term care dollars on
home and community-based services for elderly individuals and
adults with physical disabilities while \1/2\ of the States
spent less than 25 percent. This disparity continues even
though, on average, it is estimated that Medicaid dollars can
support nearly 3 elderly individuals and adults with physical
disabilities in home and community-based services for every
individual in a nursing home. Although every State has chosen
to provide certain services under home and community-based
waivers, these services are unevenly available within and
across States, and reach a small percentage of eligible
individuals.
(b) Sense of the Senate.--It is the sense of the Senate
that--
(1) during the 111th session of Congress, Congress should
address long-term services and supports in a comprehensive
way that guarantees elderly and disabled individuals the care
they need; and
(2) long term services and supports should be made
available in the community in addition to in institutions.
Subtitle F--Medicaid Prescription Drug Coverage
SEC. 2501. PRESCRIPTION DRUG REBATES.
(a) Increase in Minimum Rebate Percentage for Single Source
Drugs and Innovator Multiple Source Drugs.--
(1) In general.--Section 1927(c)(1)(B) of the Social
Security Act (42 U.S.C. 1396r-8(c)(1)(B)) is amended--
(A) in clause (i)--
(i) in subclause (IV), by striking ``and'' at the end;
(ii) in subclause (V)--
(I) by inserting ``and before January 1, 2010'' after
``December 31, 1995,''; and
(II) by striking the period at the end and inserting ``;
and''; and
(iii) by adding at the end the following new subclause:
``(VI) except as provided in clause (iii), after December
31, 2009, 23.1 percent.''; and
(B) by adding at the end the following new clause:
``(iii) Minimum rebate percentage for certain drugs.--
``(I) In general.--In the case of a single source drug or
an innovator multiple source drug described in subclause
(II), the minimum rebate percentage for rebate periods
specified in clause (i)(VI) is 17.1 percent.
``(II) Drug described.--For purposes of subclause (I), a
single source drug or an innovator multiple source drug
described in this subclause is any of the following drugs:
[[Page H1970]]
``(aa) A clotting factor for which a separate furnishing
payment is made under section 1842(o)(5) and which is
included on a list of such factors specified and updated
regularly by the Secretary.
``(bb) A drug approved by the Food and Drug Administration
exclusively for pediatric indications.''.
(2) Recapture of total savings due to increase.--Section
1927(b)(1) of such Act (42 U.S.C. 1396r-8(b)(1)) is amended
by adding at the end the following new subparagraph:
``(C) Special rule for increased minimum rebate
percentage.--
``(i) In general.--In addition to the amounts applied as a
reduction under subparagraph (B), for rebate periods
beginning on or after January 1, 2010, during a fiscal year,
the Secretary shall reduce payments to a State under section
1903(a) in the manner specified in clause (ii), in an amount
equal to the product of--
``(I) 100 percent minus the Federal medical assistance
percentage applicable to the rebate period for the State; and
``(II) the amounts received by the State under such
subparagraph that are attributable (as estimated by the
Secretary based on utilization and other data) to the
increase in the minimum rebate percentage effected by the
amendments made by subsections (a)(1), (b), and (d) of
section 2501 of the Patient Protection and Affordable Care
Act, taking into account the additional drugs included under
the amendments made by subsection (c) of section 2501 of such
Act.
The Secretary shall adjust such payment reduction for a
calendar quarter to the extent the Secretary determines,
based upon subsequent utilization and other data, that the
reduction for such quarter was greater or less than the
amount of payment reduction that should have been made.
``(ii) Manner of payment reduction.--The amount of the
payment reduction under clause (i) for a State for a quarter
shall be deemed an overpayment to the State under this title
to be disallowed against the State's regular quarterly draw
for all Medicaid spending under section 1903(d)(2). Such a
disallowance is not subject to a reconsideration under
section 1116(d).''.
(b) Increase in Rebate for Other Drugs.--Section
1927(c)(3)(B) of such Act (42 U.S.C. 1396r-8(c)(3)(B)) is
amended--
(1) in clause (i), by striking ``and'' at the end;
(2) in clause (ii)--
(A) by inserting ``and before January 1, 2010,'' after
``December 31, 1993,''; and
(B) by striking the period and inserting ``; and''; and
(3) by adding at the end the following new clause:
``(iii) after December 31, 2009, is 13 percent.''.
(c) Extension of Prescription Drug Discounts to Enrollees
of Medicaid Managed Care Organizations.--
(1) In general.--Section 1903(m)(2)(A) of such Act (42
U.S.C. 1396b(m)(2)(A)) is amended--
(A) in clause (xi), by striking ``and'' at the end;
(B) in clause (xii), by striking the period at the end and
inserting ``; and''; and
(C) by adding at the end the following:
``(xiii) such contract provides that (I) covered outpatient
drugs dispensed to individuals eligible for medical
assistance who are enrolled with the entity shall be subject
to the same rebate required by the agreement entered into
under section 1927 as the State is subject to and that the
State shall collect such rebates from manufacturers, (II)
capitation rates paid to the entity shall be based on actual
cost experience related to rebates and subject to the Federal
regulations requiring actuarially sound rates, and (III) the
entity shall report to the State, on such timely and periodic
basis as specified by the Secretary in order to include in
the information submitted by the State to a manufacturer and
the Secretary under section 1927(b)(2)(A), information on the
total number of units of each dosage form and strength and
package size by National Drug Code of each covered outpatient
drug dispensed to individuals eligible for medical assistance
who are enrolled with the entity and for which the entity is
responsible for coverage of such drug under this subsection
(other than covered outpatient drugs that under subsection
(j)(1) of section 1927 are not subject to the requirements of
that section) and such other data as the Secretary determines
necessary to carry out this subsection.''.
(2) Conforming amendments.--Section 1927 (42 U.S.C. 1396r-
8) is amended--
(A) in subsection (b)--
(i) in paragraph (1)(A), in the first sentence, by
inserting ``, including such drugs dispensed to individuals
enrolled with a medicaid managed care organization if the
organization is responsible for coverage of such drugs''
before the period; and
(ii) in paragraph (2)(A), by inserting ``including such
information reported by each medicaid managed care
organization,'' after ``for which payment was made under the
plan during the period,''; and
(B) in subsection (j), by striking paragraph (1) and
inserting the following:
``(1) Covered outpatient drugs are not subject to the
requirements of this section if such drugs are--
``(A) dispensed by health maintenance organizations,
including Medicaid managed care organizations that contract
under section 1903(m); and
``(B) subject to discounts under section 340B of the Public
Health Service Act.''.
(d) Additional Rebate for New Formulations of Existing
Drugs.--
(1) In general.--Section 1927(c)(2) of the Social Security
Act (42 U.S.C. 1396r-8(c)(2)) is amended by adding at the end
the following new subparagraph:
``(C) Treatment of new formulations.--
``(i) In general.--Except as provided in clause (ii), in
the case of a drug that is a new formulation, such as an
extended-release formulation, of a single source drug or an
innovator multiple source drug, the rebate obligation with
respect to the drug under this section shall be the amount
computed under this section for the new formulation of the
drug or, if greater, the product of--
``(I) the average manufacturer price for each dosage form
and strength of the new formulation of the single source drug
or innovator multiple source drug;
``(II) the highest additional rebate (calculated as a
percentage of average manufacturer price) under this section
for any strength of the original single source drug or
innovator multiple source drug; and
``(III) the total number of units of each dosage form and
strength of the new formulation paid for under the State plan
in the rebate period (as reported by the State).
``(ii) No application to new formulations of orphan
drugs.--Clause (i) shall not apply to a new formulation of a
covered outpatient drug that is or has been designated under
section 526 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 360bb) for a rare disease or condition, without regard
to whether the period of market exclusivity for the drug
under section 527 of such Act has expired or the specific
indication for use of the drug.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to drugs that are paid for by a State after
December 31, 2009.
(e) Maximum Rebate Amount.--Section 1927(c)(2) of such Act
(42 U.S.C. 1396r-8(c)(2)), as amended by subsection (d), is
amended by adding at the end the following new subparagraph:
``(D) Maximum rebate amount.--In no case shall the sum of
the amounts applied under paragraph (1)(A)(ii) and this
paragraph with respect to each dosage form and strength of a
single source drug or an innovator multiple source drug for a
rebate period beginning after December 31, 2009, exceed 100
percent of the average manufacturer price of the drug.''.
(f) Conforming Amendments.--
(1) In general.--Section 340B of the Public Health Service
Act (42 U.S.C. 256b) is amended--
(A) in subsection (a)(2)(B)(i), by striking ``1927(c)(4)''
and inserting ``1927(c)(3)''; and
(B) by striking subsection (c); and
(C) redesignating subsection (d) as subsection (c).
(2) Effective date.--The amendments made by this subsection
take effect on January 1, 2010.
SEC. 2502. ELIMINATION OF EXCLUSION OF COVERAGE OF CERTAIN
DRUGS.
(a) In General.--Section 1927(d) of the Social Security Act
(42 U.S.C. 1397r-8(d)) is amended--
(1) in paragraph (2)--
(A) by striking subparagraphs (E), (I), and (J),
respectively; and
(B) by redesignating subparagraphs (F), (G), (H), and (K)
as subparagraphs (E), (F), (G), and (H), respectively; and
(2) by adding at the end the following new paragraph:
``(7) Non-excludable drugs.--The following drugs or classes
of drugs, or their medical uses, shall not be excluded from
coverage:
``(A) Agents when used to promote smoking cessation,
including agents approved by the Food and Drug Administration
under the over-the-counter monograph process for purposes of
promoting, and when used to promote, tobacco cessation.
``(B) Barbiturates.
``(C) Benzodiazepines.''.
(b) Effective Date.--The amendments made by this section
shall apply to services furnished on or after January 1,
2014.
SEC. 2503. PROVIDING ADEQUATE PHARMACY REIMBURSEMENT.
(a) Pharmacy Reimbursement Limits.--
(1) In general.--Section 1927(e) of the Social Security Act
(42 U.S.C. 1396r-8(e)) is amended--
(A) in paragraph (4), by striking ``(or, effective January
1, 2007, two or more)''; and
(B) by striking paragraph (5) and inserting the following:
``(5) Use of amp in upper payment limits.--The Secretary
shall calculate the Federal upper reimbursement limit
established under paragraph (4) as no less than 175 percent
of the weighted average (determined on the basis of
utilization) of the most recently reported monthly average
manufacturer prices for pharmaceutically and therapeutically
equivalent multiple source drug products that are available
for purchase by retail community pharmacies on a nationwide
basis. The Secretary shall implement a smoothing process for
average manufacturer prices. Such process shall be similar to
the smoothing process used in determining the average sales
price of a drug or biological under section 1847A.''.
(2) Definition of amp.--Section 1927(k)(1) of such Act (42
U.S.C. 1396r-8(k)(1)) is amended--
(A) in subparagraph (A), by striking ``by'' and all that
follows through the period and inserting ``by--
``(i) wholesalers for drugs distributed to retail community
pharmacies; and
``(ii) retail community pharmacies that purchase drugs
directly from the manufacturer.''; and
(B) by striking subparagraph (B) and inserting the
following:
``(B) Exclusion of customary prompt pay discounts and other
payments.--
``(i) In general.--The average manufacturer price for a
covered outpatient drug shall exclude--
``(I) customary prompt pay discounts extended to
wholesalers;
``(II) bona fide service fees paid by manufacturers to
wholesalers or retail community pharmacies, including (but
not limited to) distribution service fees, inventory
management fees,
[[Page H1971]]
product stocking allowances, and fees associated with
administrative services agreements and patient care programs
(such as medication compliance programs and patient education
programs);
``(III) reimbursement by manufacturers for recalled,
damaged, expired, or otherwise unsalable returned goods,
including (but not limited to) reimbursement for the cost of
the goods and any reimbursement of costs associated with
return goods handling and processing, reverse logistics, and
drug destruction; and
``(IV) payments received from, and rebates or discounts
provided to, pharmacy benefit managers, managed care
organizations, health maintenance organizations, insurers,
hospitals, clinics, mail order pharmacies, long term care
providers, manufacturers, or any other entity that does not
conduct business as a wholesaler or a retail community
pharmacy.
``(ii) Inclusion of other discounts and payments.--
Notwithstanding clause (i), any other discounts, rebates,
payments, or other financial transactions that are received
by, paid by, or passed through to, retail community
pharmacies shall be included in the average manufacturer
price for a covered outpatient drug.''; and
(C) in subparagraph (C), by striking ``the retail pharmacy
class of trade'' and inserting ``retail community
pharmacies''.
(3) Definition of multiple source drug.--Section 1927(k)(7)
of such Act (42 U.S.C. 1396r-8(k)(7)) is amended--
(A) in subparagraph (A)(i)(III), by striking ``the State''
and inserting ``the United States''; and
(B) in subparagraph (C)--
(i) in clause (i), by inserting ``and'' after the
semicolon;
(ii) in clause (ii), by striking ``; and'' and inserting a
period; and
(iii) by striking clause (iii).
(4) Definitions of retail community pharmacy; wholesaler.--
Section 1927(k) of such Act (42 U.S.C. 1396r-8(k)) is amended
by adding at the end the following new paragraphs:
``(10) Retail community pharmacy.--The term `retail
community pharmacy' means an independent pharmacy, a chain
pharmacy, a supermarket pharmacy, or a mass merchandiser
pharmacy that is licensed as a pharmacy by the State and that
dispenses medications to the general public at retail prices.
Such term does not include a pharmacy that dispenses
prescription medications to patients primarily through the
mail, nursing home pharmacies, long-term care facility
pharmacies, hospital pharmacies, clinics, charitable or not-
for-profit pharmacies, government pharmacies, or pharmacy
benefit managers.
``(11) Wholesaler.--The term `wholesaler' means a drug
wholesaler that is engaged in wholesale distribution of
prescription drugs to retail community pharmacies, including
(but not limited to) manufacturers, repackers, distributors,
own-label distributors, private-label distributors, jobbers,
brokers, warehouses (including manufacturer's and
distributor's warehouses, chain drug warehouses, and
wholesale drug warehouses) independent wholesale drug
traders, and retail community pharmacies that conduct
wholesale distributions.''.
(b) Disclosure of Price Information to the Public.--Section
1927(b)(3) of such Act (42 U.S.C. 1396r-8(b)(3)) is amended--
(1) in subparagraph (A)--
(A) in the first sentence, by inserting after clause (iii)
the following:
``(iv) not later than 30 days after the last day of each
month of a rebate period under the agreement, on the
manufacturer's total number of units that are used to
calculate the monthly average manufacturer price for each
covered outpatient drug;''; and
(B) in the second sentence, by inserting ``(relating to the
weighted average of the most recently reported monthly
average manufacturer prices)'' after ``(D)(v)''; and
(2) in subparagraph (D)(v), by striking ``average
manufacturer prices'' and inserting ``the weighted average of
the most recently reported monthly average manufacturer
prices and the average retail survey price determined for
each multiple source drug in accordance with subsection
(f)''.
(c) Clarification of Application of Survey of Retail
Prices.--Section 1927(f)(1) of such Act (42 U.S.C. 1396r-
8(b)(1)) is amended--
(1) in subparagraph (A)(i), by inserting ``with respect to
a retail community pharmacy,'' before ``the determination'';
and
(2) in subparagraph (C)(ii), by striking ``retail
pharmacies'' and inserting ``retail community pharmacies''.
(d) Effective Date.--The amendments made by this section
shall take effect on the first day of the first calendar year
quarter that begins at least 180 days after the date of
enactment of this Act, without regard to whether or not final
regulations to carry out such amendments have been
promulgated by such date.
Subtitle G--Medicaid Disproportionate Share Hospital (DSH) Payments
SEC. 2551. DISPROPORTIONATE SHARE HOSPITAL PAYMENTS.
(a) In General.--Section 1923(f) of the Social Security Act
(42 U.S.C. 1396r-4(f)) is amended--
(1) in paragraph (1), by striking ``and (3)'' and inserting
``, (3), and (7)'';
(2) in paragraph (3)(A), by striking ``paragraph (6)'' and
inserting ``paragraphs (6) and (7)'';
(3) by redesignating paragraph (7) as paragraph (8); and
(4) by inserting after paragraph (6) the following new
paragraph:
``(7) Reduction of state dsh allotments once reduction in
uninsured threshold reached.--
``(A) In general.--Subject to subparagraph (E), the DSH
allotment for a State for fiscal years beginning with the
fiscal year described in subparagraph (C) (with respect to
the State), is equal to--
``(i) in the case of the first fiscal year described in
subparagraph (C) with respect to a State, the DSH allotment
that would be determined under this subsection for the State
for the fiscal year without application of this paragraph
(but after the application of subparagraph (D)), reduced by
the applicable percentage determined for the State for the
fiscal year under subparagraph (B)(i); and
``(ii) in the case of any subsequent fiscal year with
respect to the State, the DSH allotment determined under this
paragraph for the State for the preceding fiscal year,
reduced by the applicable percentage determined for the State
for the fiscal year under subparagraph (B)(ii).
``(B) Applicable percentage.--For purposes of subparagraph
(A), the applicable percentage for a State for a fiscal year
is the following:
``(i) Uninsured reduction threshold fiscal year.--In the
case of the first fiscal year described in subparagraph (C)
with respect to the State--
``(I) if the State is a low DSH State described in
paragraph (5)(B), the applicable percentage is equal to 25
percent; and
``(II) if the State is any other State, the applicable
percentage is 50 percent.
``(ii) Subsequent fiscal years in which the percentage of
uninsured decreases.--In the case of any fiscal year after
the first fiscal year described in subparagraph (C) with
respect to a State, if the Secretary determines on the basis
of the most recent American Community Survey of the Bureau of
the Census, that the percentage of uncovered individuals
residing in the State is less than the percentage of such
individuals determined for the State for the preceding fiscal
year--
``(I) if the State is a low DSH State described in
paragraph (5)(B), the applicable percentage is equal to the
product of the percentage reduction in uncovered individuals
for the fiscal year from the preceding fiscal year and 25
percent; and
``(II) if the State is any other State, the applicable
percentage is equal to the product of the percentage
reduction in uncovered individuals for the fiscal year from
the preceding fiscal year and 50 percent.
``(C) Fiscal year described.--For purposes of subparagraph
(A), the fiscal year described in this subparagraph with
respect to a State is the first fiscal year that occurs after
fiscal year 2012 for which the Secretary determines, on the
basis of the most recent American Community Survey of the
Bureau of the Census, that the percentage of uncovered
individuals residing in the State is at least 45 percent less
than the percentage of such individuals determined for the
State for fiscal year 2009.
``(D) Exclusion of portions diverted for coverage
expansions.--For purposes of applying the applicable
percentage reduction under subparagraph (A) to the DSH
allotment for a State for a fiscal year, the DSH allotment
for a State that would be determined under this subsection
for the State for the fiscal year without the application of
this paragraph (and prior to any such reduction) shall not
include any portion of the allotment for which the Secretary
has approved the State's diversion to the costs of providing
medical assistance or other health benefits coverage under a
waiver that is in effect on July 2009.
``(E) Minimum allotment.--In no event shall the DSH
allotment determined for a State in accordance with this
paragraph for fiscal year 2013 or any succeeding fiscal year
be less than the amount equal to 35 percent of the DSH
allotment determined for the State for fiscal year 2012 under
this subsection (and after the application of this paragraph,
if applicable), increased by the percentage change in the
consumer price index for all urban consumers (all items, U.S.
city average) for each previous fiscal year occurring before
the fiscal year.
``(F) Uncovered individuals.--In this paragraph, the term
`uncovered individuals' means individuals with no health
insurance coverage at any time during a year (as determined
by the Secretary based on the most recent data available).''.
(b) Effective Date.--The amendments made by subsection (a)
take effect on October 1, 2011.
Subtitle H--Improved Coordination for Dual Eligible Beneficiaries
SEC. 2601. 5-YEAR PERIOD FOR DEMONSTRATION PROJECTS.
(a) In General.--Section 1915(h) of the Social Security Act
(42 U.S.C. 1396n(h)) is amended--
(1) by inserting ``(1)'' after ``(h)'';
(2) by inserting ``, or a waiver described in paragraph
(2)'' after ``(e)''; and
(3) by adding at the end the following new paragraph:
``(2)(A) Notwithstanding subsections (c)(3) and (d) (3),
any waiver under subsection (b), (c), or (d), or a waiver
under section 1115, that provides medical assistance for dual
eligible individuals (including any such waivers under which
non dual eligible individuals may be enrolled in addition to
dual eligible individuals) may be conducted for a period of 5
years and, upon the request of the State, may be extended for
additional 5-year periods unless the Secretary determines
that for the previous waiver period the conditions for the
waiver have not been met or it would no longer be cost-
effective and efficient, or consistent with the purposes of
this title, to extend the waiver.
``(B) In this paragraph, the term `dual eligible
individual' means an individual who is entitled to, or
enrolled for, benefits under part A of title XVIII, or
enrolled for benefits under part B of title XVIII, and is
eligible for medical assistance under the State plan under
this title or under a waiver of such plan.''.
(b) Conforming Amendments.--
[[Page H1972]]
(1) Section 1915 of such Act (42 U.S.C. 1396n) is amended--
(A) in subsection (b), by adding at the end the following
new sentence: ``Subsection (h)(2) shall apply to a waiver
under this subsection.'';
(B) in subsection (c)(3), in the second sentence, by
inserting ``(other than a waiver described in subsection
(h)(2))'' after ``A waiver under this subsection'';
(C) in subsection (d)(3), in the second sentence, by
inserting ``(other than a waiver described in subsection
(h)(2))'' after ``A waiver under this subsection''.
(2) Section 1115 of such Act (42 U.S.C. 1315) is amended--
(A) in subsection (e)(2), by inserting ``(5 years, in the
case of a waiver described in section 1915(h)(2))'' after ``3
years''; and
(B) in subsection (f)(6), by inserting ``(5 years, in the
case of a waiver described in section 1915(h)(2))'' after ``3
years''.
SEC. 2602. PROVIDING FEDERAL COVERAGE AND PAYMENT
COORDINATION FOR DUAL ELIGIBLE BENEFICIARIES.
(a) Establishment of Federal Coordinated Health Care
Office.--
(1) In general.--Not later than March 1, 2010, the
Secretary of Health and Human Services (in this section
referred to as the ``Secretary'') shall establish a Federal
Coordinated Health Care Office.
(2) Establishment and reporting to cms administrator.--The
Federal Coordinated Health Care Office--
(A) shall be established within the Centers for Medicare &
Medicaid Services; and
(B) have as the Office a Director who shall be appointed
by, and be in direct line of authority to, the Administrator
of the Centers for Medicare & Medicaid Services.
(b) Purpose.--The purpose of the Federal Coordinated Health
Care Office is to bring together officers and employees of
the Medicare and Medicaid programs at the Centers for
Medicare & Medicaid Services in order to--
(1) more effectively integrate benefits under the Medicare
program under title XVIII of the Social Security Act and the
Medicaid program under title XIX of such Act; and
(2) improve the coordination between the Federal Government
and States for individuals eligible for benefits under both
such programs in order to ensure that such individuals get
full access to the items and services to which they are
entitled under titles XVIII and XIX of the Social Security
Act.
(c) Goals.--The goals of the Federal Coordinated Health
Care Office are as follows:
(1) Providing dual eligible individuals full access to the
benefits to which such individuals are entitled under the
Medicare and Medicaid programs.
(2) Simplifying the processes for dual eligible individuals
to access the items and services they are entitled to under
the Medicare and Medicaid programs.
(3) Improving the quality of health care and long-term
services for dual eligible individuals.
(4) Increasing dual eligible individuals' understanding of
and satisfaction with coverage under the Medicare and
Medicaid programs.
(5) Eliminating regulatory conflicts between rules under
the Medicare and Medicaid programs.
(6) Improving care continuity and ensuring safe and
effective care transitions for dual eligible individuals.
(7) Eliminating cost-shifting between the Medicare and
Medicaid program and among related health care providers.
(8) Improving the quality of performance of providers of
services and suppliers under the Medicare and Medicaid
programs.
(d) Specific Responsibilities.--The specific
responsibilities of the Federal Coordinated Health Care
Office are as follows:
(1) Providing States, specialized MA plans for special
needs individuals (as defined in section 1859(b)(6) of the
Social Security Act (42 U.S.C. 1395w-28(b)(6))), physicians
and other relevant entities or individuals with the education
and tools necessary for developing programs that align
benefits under the Medicare and Medicaid programs for dual
eligible individuals.
(2) Supporting State efforts to coordinate and align acute
care and long-term care services for dual eligible
individuals with other items and services furnished under the
Medicare program.
(3) Providing support for coordination of contracting and
oversight by States and the Centers for Medicare & Medicaid
Services with respect to the integration of the Medicare and
Medicaid programs in a manner that is supportive of the goals
described in paragraph (3).
(4) To consult and coordinate with the Medicare Payment
Advisory Commission established under section 1805 of the
Social Security Act (42 U.S.C. 1395b-6) and the Medicaid and
CHIP Payment and Access Commission established under section
1900 of such Act (42 U.S.C. 1396) with respect to policies
relating to the enrollment in, and provision of, benefits to
dual eligible individuals under the Medicare program under
title XVIII of the Social Security Act and the Medicaid
program under title XIX of such Act.
(5) To study the provision of drug coverage for new full-
benefit dual eligible individuals (as defined in section
1935(c)(6) of the Social Security Act (42 U.S.C. 1396u-
5(c)(6)), as well as to monitor and report annual total
expenditures, health outcomes, and access to benefits for all
dual eligible individuals.
(e) Report.--The Secretary shall, as part of the budget
transmitted under section 1105(a) of title 31, United States
Code, submit to Congress an annual report containing
recommendations for legislation that would improve care
coordination and benefits for dual eligible individuals.
(f) Dual Eligible Defined.--In this section, the term
``dual eligible individual'' means an individual who is
entitled to, or enrolled for, benefits under part A of title
XVIII of the Social Security Act, or enrolled for benefits
under part B of title XVIII of such Act, and is eligible for
medical assistance under a State plan under title XIX of such
Act or under a waiver of such plan.
Subtitle I--Improving the Quality of Medicaid for Patients and
Providers
SEC. 2701. ADULT HEALTH QUALITY MEASURES.
Title XI of the Social Security Act (42 U.S.C. 1301 et
seq.), as amended by section 401 of the Children's Health
Insurance Program Reauthorization Act of 2009 (Public Law
111-3), is amended by inserting after section 1139A the
following new section:
``SEC. 1139B. ADULT HEALTH QUALITY MEASURES.
``(a) Development of Core Set of Health Care Quality
Measures for Adults Eligible for Benefits Under Medicaid.--
The Secretary shall identify and publish a recommended core
set of adult health quality measures for Medicaid eligible
adults in the same manner as the Secretary identifies and
publishes a core set of child health quality measures under
section 1139A, including with respect to identifying and
publishing existing adult health quality measures that are in
use under public and privately sponsored health care coverage
arrangements, or that are part of reporting systems that
measure both the presence and duration of health insurance
coverage over time, that may be applicable to Medicaid
eligible adults.
``(b) Deadlines.--
``(1) Recommended measures.--Not later than January 1,
2011, the Secretary shall identify and publish for comment a
recommended core set of adult health quality measures for
Medicaid eligible adults.
``(2) Dissemination.--Not later than January 1, 2012, the
Secretary shall publish an initial core set of adult health
quality measures that are applicable to Medicaid eligible
adults.
``(3) Standardized reporting.--Not later than January 1,
2013, the Secretary, in consultation with States, shall
develop a standardized format for reporting information based
on the initial core set of adult health quality measures and
create procedures to encourage States to use such measures to
voluntarily report information regarding the quality of
health care for Medicaid eligible adults.
``(4) Reports to congress.--Not later than January 1, 2014,
and every 3 years thereafter, the Secretary shall include in
the report to Congress required under section 1139A(a)(6)
information similar to the information required under that
section with respect to the measures established under this
section.
``(5) Establishment of medicaid quality measurement
program.--
``(A) In general.--Not later than 12 months after the
release of the recommended core set of adult health quality
measures under paragraph (1)), the Secretary shall establish
a Medicaid Quality Measurement Program in the same manner as
the Secretary establishes the pediatric quality measures
program under section 1139A(b). The aggregate amount awarded
by the Secretary for grants and contracts for the
development, testing, and validation of emerging and
innovative evidence-based measures under such program shall
equal the aggregate amount awarded by the Secretary for
grants under section 1139A(b)(4)(A)
``(B) Revising, strengthening, and improving initial core
measures.--Beginning not later than 24 months after the
establishment of the Medicaid Quality Measurement Program,
and annually thereafter, the Secretary shall publish
recommended changes to the initial core set of adult health
quality measures that shall reflect the results of the
testing, validation, and consensus process for the
development of adult health quality measures.
``(c) Construction.--Nothing in this section shall be
construed as supporting the restriction of coverage, under
title XIX or XXI or otherwise, to only those services that
are evidence-based, or in anyway limiting available services.
``(d) Annual State Reports Regarding State-Specific Quality
of Care Measures Applied Under Medicaid.--
``(1) Annual state reports.--Each State with a State plan
or waiver approved under title XIX shall annually report
(separately or as part of the annual report required under
section 1139A(c)), to the Secretary on the--
``(A) State-specific adult health quality measures applied
by the State under the such plan, including measures
described in subsection (a)(5); and
``(B) State-specific information on the quality of health
care furnished to Medicaid eligible adults under such plan,
including information collected through external quality
reviews of managed care organizations under section 1932 and
benchmark plans under section 1937.
``(2) Publication.--Not later than September 30, 2014, and
annually thereafter, the Secretary shall collect, analyze,
and make publicly available the information reported by
States under paragraph (1).
``(e) Appropriation.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated for each of
fiscal years 2010 through 2014, $60,000,000 for the purpose
of carrying out this section. Funds appropriated under this
subsection shall remain available until expended.''.
SEC. 2702. PAYMENT ADJUSTMENT FOR HEALTH CARE-ACQUIRED
CONDITIONS.
(a) In General.--The Secretary of Health and Human Services
(in this subsection referred to as the ``Secretary'') shall
identify current State practices that prohibit payment for
health care-acquired conditions and shall incorporate the
practices identified, or elements of such practices, which
the Secretary determines appropriate for application to the
Medicaid program in regulations. Such regulations shall be
effective as of July 1, 2011, and shall prohibit payments to
States under section 1903 of the Social
[[Page H1973]]
Security Act for any amounts expended for providing medical
assistance for health care-acquired conditions specified in
the regulations. The regulations shall ensure that the
prohibition on payment for health care-acquired conditions
shall not result in a loss of access to care or services for
Medicaid beneficiaries.
(b) Health Care-Acquired Condition.--In this section. the
term ``health care-acquired condition'' means a medical
condition for which an individual was diagnosed that could be
identified by a secondary diagnostic code described in
section 1886(d)(4)(D)(iv) of the Social Security Act (42
U.S.C. 1395ww(d)(4)(D)(iv)).
(c) Medicare Provisions.--In carrying out this section, the
Secretary shall apply to State plans (or waivers) under title
XIX of the Social Security Act the regulations promulgated
pursuant to section 1886(d)(4)(D) of such Act (42 U.S.C.
1395ww(d)(4)(D)) relating to the prohibition of payments
based on the presence of a secondary diagnosis code specified
by the Secretary in such regulations, as appropriate for the
Medicaid program. The Secretary may exclude certain
conditions identified under title XVIII of the Social
Security Act for non-payment under title XIX of such Act when
the Secretary finds the inclusion of such conditions to be
inapplicable to beneficiaries under title XIX.
SEC. 2703. STATE OPTION TO PROVIDE HEALTH HOMES FOR ENROLLEES
WITH CHRONIC CONDITIONS.
(a) State Plan Amendment.--Title XIX of the Social Security
Act (42 U.S.C. 1396a et seq.), as amended by sections 2201
and 2305, is amended by adding at the end the following new
section:
``Sec. 1945. State Option To Provide Coordinated Care
Through a Health Home for Individuals With Chronic
Conditions.--
``(a) In General.--Notwithstanding section 1902(a)(1)
(relating to statewideness), section 1902(a)(10)(B) (relating
to comparability), and any other provision of this title for
which the Secretary determines it is necessary to waive in
order to implement this section, beginning January 1, 2011, a
State, at its option as a State plan amendment, may provide
for medical assistance under this title to eligible
individuals with chronic conditions who select a designated
provider (as described under subsection (h)(5)), a team of
health care professionals (as described under subsection
(h)(6)) operating with such a provider, or a health team (as
described under subsection (h)(7)) as the individual's health
home for purposes of providing the individual with health
home services.
``(b) Health Home Qualification Standards.--The Secretary
shall establish standards for qualification as a designated
provider for the purpose of being eligible to be a health
home for purposes of this section.
``(c) Payments.--
``(1) In general.--A State shall provide a designated
provider, a team of health care professionals operating with
such a provider, or a health team with payments for the
provision of health home services to each eligible individual
with chronic conditions that selects such provider, team of
health care professionals, or health team as the individual's
health home. Payments made to a designated provider, a team
of health care professionals operating with such a provider,
or a health team for such services shall be treated as
medical assistance for purposes of section 1903(a), except
that, during the first 8 fiscal year quarters that the State
plan amendment is in effect, the Federal medical assistance
percentage applicable to such payments shall be equal to 90
percent.
``(2) Methodology.--
``(A) In general.--The State shall specify in the State
plan amendment the methodology the State will use for
determining payment for the provision of health home
services. Such methodology for determining payment--
``(i) may be tiered to reflect, with respect to each
eligible individual with chronic conditions provided such
services by a designated provider, a team of health care
professionals operating with such a provider, or a health
team, as well as the severity or number of each such
individual's chronic conditions or the specific capabilities
of the provider, team of health care professionals, or health
team; and
``(ii) shall be established consistent with section
1902(a)(30)(A).
``(B) Alternate models of payment.--The methodology for
determining payment for provision of health home services
under this section shall not be limited to a per-member per-
month basis and may provide (as proposed by the State and
subject to approval by the Secretary) for alternate models of
payment.
``(3) Planning grants.--
``(A) In general.--Beginning January 1, 2011, the Secretary
may award planning grants to States for purposes of
developing a State plan amendment under this section. A
planning grant awarded to a State under this paragraph shall
remain available until expended.
``(B) State contribution.--A State awarded a planning grant
shall contribute an amount equal to the State percentage
determined under section 1905(b) (without regard to section
5001 of Public Law 111-5) for each fiscal year for which the
grant is awarded.
``(C) Limitation.--The total amount of payments made to
States under this paragraph shall not exceed $25,000,000.
``(d) Hospital Referrals.--A State shall include in the
State plan amendment a requirement for hospitals that are
participating providers under the State plan or a waiver of
such plan to establish procedures for referring any eligible
individuals with chronic conditions who seek or need
treatment in a hospital emergency department to designated
providers.
``(e) Coordination.--A State shall consult and coordinate,
as appropriate, with the Substance Abuse and Mental Health
Services Administration in addressing issues regarding the
prevention and treatment of mental illness and substance
abuse among eligible individuals with chronic conditions.
``(f) Monitoring.--A State shall include in the State plan
amendment--
``(1) a methodology for tracking avoidable hospital
readmissions and calculating savings that result from
improved chronic care coordination and management under this
section; and
``(2) a proposal for use of health information technology
in providing health home services under this section and
improving service delivery and coordination across the care
continuum (including the use of wireless patient technology
to improve coordination and management of care and patient
adherence to recommendations made by their provider).
``(g) Report on Quality Measures.--As a condition for
receiving payment for health home services provided to an
eligible individual with chronic conditions, a designated
provider shall report to the State, in accordance with such
requirements as the Secretary shall specify, on all
applicable measures for determining the quality of such
services. When appropriate and feasible, a designated
provider shall use health information technology in providing
the State with such information.
``(h) Definitions.--In this section:
``(1) Eligible individual with chronic conditions.--
``(A) In general.--Subject to subparagraph (B), the term
`eligible individual with chronic conditions' means an
individual who--
``(i) is eligible for medical assistance under the State
plan or under a waiver of such plan; and
``(ii) has at least--
``(I) 2 chronic conditions;
``(II) 1 chronic condition and is at risk of having a
second chronic condition; or
``(III) 1 serious and persistent mental health condition.
``(B) Rule of construction.--Nothing in this paragraph
shall prevent the Secretary from establishing higher levels
as to the number or severity of chronic or mental health
conditions for purposes of determining eligibility for
receipt of health home services under this section.
``(2) Chronic condition.--The term `chronic condition' has
the meaning given that term by the Secretary and shall
include, but is not limited to, the following:
``(A) A mental health condition.
``(B) Substance use disorder.
``(C) Asthma.
``(D) Diabetes.
``(E) Heart disease.
``(F) Being overweight, as evidenced by having a Body Mass
Index (BMI) over 25.
``(3) Health home.--The term `health home' means a
designated provider (including a provider that operates in
coordination with a team of health care professionals) or a
health team selected by an eligible individual with chronic
conditions to provide health home services.
``(4) Health home services.--
``(A) In general.--The term `health home services' means
comprehensive and timely high-quality services described in
subparagraph (B) that are provided by a designated provider,
a team of health care professionals operating with such a
provider, or a health team.
``(B) Services described.--The services described in this
subparagraph are--
``(i) comprehensive care management;
``(ii) care coordination and health promotion;
``(iii) comprehensive transitional care, including
appropriate follow-up, from inpatient to other settings;
``(iv) patient and family support (including authorized
representatives);
``(v) referral to community and social support services, if
relevant; and
``(vi) use of health information technology to link
services, as feasible and appropriate.
``(5) Designated provider.--The term `designated provider'
means a physician, clinical practice or clinical group
practice, rural clinic, community health center, community
mental health center, home health agency, or any other entity
or provider (including pediatricians, gynecologists, and
obstetricians) that is determined by the State and approved
by the Secretary to be qualified to be a health home for
eligible individuals with chronic conditions on the basis of
documentation evidencing that the physician, practice, or
clinic--
``(A) has the systems and infrastructure in place to
provide health home services; and
``(B) satisfies the qualification standards established by
the Secretary under subsection (b).
``(6) Team of health care professionals.--The term `team of
health care professionals' means a team of health
professionals (as described in the State plan amendment) that
may--
``(A) include physicians and other professionals, such as a
nurse care coordinator, nutritionist, social worker,
behavioral health professional, or any professionals deemed
appropriate by the State; and
``(B) be free standing, virtual, or based at a hospital,
community health center, community mental health center,
rural clinic, clinical practice or clinical group practice,
academic health center, or any entity deemed appropriate by
the State and approved by the Secretary.
``(7) Health team.--The term `health team' has the meaning
given such term for purposes of section 3502 of the Patient
Protection and Affordable Care Act.''.
(b) Evaluation.--
(1) Independent evaluation.--
(A) In general.--The Secretary shall enter into a contract
with an independent entity or organization to conduct an
evaluation and assessment of the States that have elected the
option to provide coordinated care through a health home for
Medicaid beneficiaries with chronic conditions under section
1945 of the Social Security Act (as added by subsection (a))
for the purpose of determining the effect of such
[[Page H1974]]
option on reducing hospital admissions, emergency room
visits, and admissions to skilled nursing facilities.
(B) Evaluation report.--Not later than January 1, 2017, the
Secretary shall report to Congress on the evaluation and
assessment conducted under subparagraph (A).
(2) Survey and interim report.--
(A) In general.--Not later than January 1, 2014, the
Secretary of Health and Human Services shall survey States
that have elected the option under section 1945 of the Social
Security Act (as added by subsection (a)) and report to
Congress on the nature, extent, and use of such option,
particularly as it pertains to--
(i) hospital admission rates;
(ii) chronic disease management;
(iii) coordination of care for individuals with chronic
conditions;
(iv) assessment of program implementation;
(v) processes and lessons learned (as described in
subparagraph (B));
(vi) assessment of quality improvements and clinical
outcomes under such option; and
(vii) estimates of cost savings.
(B) Implementation reporting.--A State that has elected
the option under section 1945 of the Social Security Act (as
added by subsection (a)) shall report to the Secretary, as
necessary, on processes that have been developed and lessons
learned regarding provision of coordinated care through a
health home for Medicaid beneficiaries with chronic
conditions under such option.
SEC. 2704. DEMONSTRATION PROJECT TO EVALUATE INTEGRATED CARE
AROUND A HOSPITALIZATION.
(a) Authority To Conduct Project.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
establish a demonstration project under title XIX of the
Social Security Act to evaluate the use of bundled payments
for the provision of integrated care for a Medicaid
beneficiary--
(A) with respect to an episode of care that includes a
hospitalization; and
(B) for concurrent physicians services provided during a
hospitalization.
(2) Duration.--The demonstration project shall begin on
January 1, 2012, and shall end on December 31, 2016.
(b) Requirements.--The demonstration project shall be
conducted in accordance with the following:
(1) The demonstration project shall be conducted in up to 8
States, determined by the Secretary based on consideration of
the potential to lower costs under the Medicaid program while
improving care for Medicaid beneficiaries. A State selected
to participate in the demonstration project may target the
demonstration project to particular categories of
beneficiaries, beneficiaries with particular diagnoses, or
particular geographic regions of the State, but the Secretary
shall insure that, as a whole, the demonstration project is,
to the greatest extent possible, representative of the
demographic and geographic composition of Medicaid
beneficiaries nationally.
(2) The demonstration project shall focus on conditions
where there is evidence of an opportunity for providers of
services and suppliers to improve the quality of care
furnished to Medicaid beneficiaries while reducing total
expenditures under the State Medicaid programs selected to
participate, as determined by the Secretary.
(3) A State selected to participate in the demonstration
project shall specify the 1 or more episodes of care the
State proposes to address in the project, the services to be
included in the bundled payments, and the rationale for the
selection of such episodes of care and services. The
Secretary may modify the episodes of care as well as the
services to be included in the bundled payments prior to or
after approving the project. The Secretary may also vary such
factors among the different States participating in the
demonstration project.
(4) The Secretary shall ensure that payments made under the
demonstration project are adjusted for severity of illness
and other characteristics of Medicaid beneficiaries within a
category or having a diagnosis targeted as part of the
demonstration project. States shall ensure that Medicaid
beneficiaries are not liable for any additional cost sharing
than if their care had not been subject to payment under the
demonstration project.
(5) Hospitals participating in the demonstration project
shall have or establish robust discharge planning programs to
ensure that Medicaid beneficiaries requiring post-acute care
are appropriately placed in, or have ready access to, post-
acute care settings.
(6) The Secretary and each State selected to participate in
the demonstration project shall ensure that the demonstration
project does not result in the Medicaid beneficiaries whose
care is subject to payment under the demonstration project
being provided with less items and services for which medical
assistance is provided under the State Medicaid program than
the items and services for which medical assistance would
have been provided to such beneficiaries under the State
Medicaid program in the absence of the demonstration project.
(c) Waiver of Provisions.--Notwithstanding section 1115(a)
of the Social Security Act (42 U.S.C. 1315(a)), the Secretary
may waive such provisions of titles XIX, XVIII, and XI of
that Act as may be necessary to accomplish the goals of the
demonstration, ensure beneficiary access to acute and post-
acute care, and maintain quality of care.
(d) Evaluation and Report.--
(1) Data.--Each State selected to participate in the
demonstration project under this section shall provide to the
Secretary, in such form and manner as the Secretary shall
specify, relevant data necessary to monitor outcomes, costs,
and quality, and evaluate the rationales for selection of the
episodes of care and services specified by States under
subsection (b)(3).
(2) Report.--Not later than 1 year after the conclusion of
the demonstration project, the Secretary shall submit a
report to Congress on the results of the demonstration
project.
SEC. 2705. MEDICAID GLOBAL PAYMENT SYSTEM DEMONSTRATION
PROJECT.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary'') shall, in
coordination with the Center for Medicare and Medicaid
Innovation (as established under section 1115A of the Social
Security Act, as added by section 3021 of this Act),
establish the Medicaid Global Payment System Demonstration
Project under which a participating State shall adjust the
payments made to an eligible safety net hospital system or
network from a fee-for-service payment structure to a global
capitated payment model.
(b) Duration and Scope.--The demonstration project
conducted under this section shall operate during a period of
fiscal years 2010 through 2012. The Secretary shall select
not more than 5 States to participate in the demonstration
project.
(c) Eligible Safety Net Hospital System or Network.--For
purposes of this section, the term ``eligible safety net
hospital system or network'' means a large, safety net
hospital system or network (as defined by the Secretary) that
operates within a State selected by the Secretary under
subsection (b).
(d) Evaluation.--
(1) Testing.--The Innovation Center shall test and evaluate
the demonstration project conducted under this section to
examine any changes in health care quality outcomes and
spending by the eligible safety net hospital systems or
networks.
(2) Budget neutrality.--During the testing period under
paragraph (1), any budget neutrality requirements under
section 1115A(b)(3) of the Social Security Act (as so added)
shall not be applicable.
(3) Modification.--During the testing period under
paragraph (1), the Secretary may, in the Secretary's
discretion, modify or terminate the demonstration project
conducted under this section.
(e) Report.--Not later than 12 months after the date of
completion of the demonstration project under this section,
the Secretary shall submit to Congress a report containing
the results of the evaluation and testing conducted under
subsection (d), together with recommendations for such
legislation and administrative action as the Secretary
determines appropriate.
(f) Authorization of Appropriations.--There are authorized
to be appropriated such sums as are necessary to carry out
this section.
SEC. 2706. PEDIATRIC ACCOUNTABLE CARE ORGANIZATION
DEMONSTRATION PROJECT.
(a) Authority To Conduct Demonstration.--
(1) In general.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary'') shall
establish the Pediatric Accountable Care Organization
Demonstration Project to authorize a participating State to
allow pediatric medical providers that meet specified
requirements to be recognized as an accountable care
organization for purposes of receiving incentive payments (as
described under subsection (d)), in the same manner as an
accountable care organization is recognized and provided with
incentive payments under section 1899 of the Social Security
Act (as added by section 3022).
(2) Duration.--The demonstration project shall begin on
January 1, 2012, and shall end on December 31, 2016.
(b) Application.--A State that desires to participate in
the demonstration project under this section shall submit to
the Secretary an application at such time, in such manner,
and containing such information as the Secretary may require.
(c) Requirements.--
(1) Performance guidelines.--The Secretary, in consultation
with the States and pediatric providers, shall establish
guidelines to ensure that the quality of care delivered to
individuals by a provider recognized as an accountable care
organization under this section is not less than the quality
of care that would have otherwise been provided to such
individuals.
(2) Savings requirement.--A participating State, in
consultation with the Secretary, shall establish an annual
minimal level of savings in expenditures for items and
services covered under the Medicaid program under title XIX
of the Social Security Act and the CHIP program under title
XXI of such Act that must be reached by an accountable care
organization in order for such organization to receive an
incentive payment under subsection (d).
(3) Minimum participation period.--A provider desiring to
be recognized as an accountable care organization under the
demonstration project shall enter into an agreement with the
State to participate in the project for not less than a 3-
year period.
(d) Incentive Payment.--An accountable care organization
that meets the performance guidelines established by the
Secretary under subsection (c)(1) and achieves savings
greater than the annual minimal savings level established by
the State under subsection (c)(2) shall receive an incentive
payment for such year equal to a portion (as determined
appropriate by the Secretary) of the amount of such excess
savings. The Secretary may establish an annual cap on
incentive payments for an accountable care organization.
(e) Authorization of Appropriations.--There are authorized
to be appropriated such sums as are necessary to carry out
this section.
[[Page H1975]]
SEC. 2707. MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION
PROJECT.
(a) Authority To Conduct Demonstration Project.--The
Secretary of Health and Human Services (in this section
referred to as the ``Secretary'') shall establish a
demonstration project under which an eligible State (as
described in subsection (c)) shall provide payment under the
State Medicaid plan under title XIX of the Social Security
Act to an institution for mental diseases that is not
publicly owned or operated and that is subject to the
requirements of section 1867 of the Social Security Act (42
U.S.C. 1395dd) for the provision of medical assistance
available under such plan to individuals who--
(1) have attained age 21, but have not attained age 65;
(2) are eligible for medical assistance under such plan;
and
(3) require such medical assistance to stabilize an
emergency medical condition.
(b) Stabilization Review.--A State shall specify in its
application described in subsection (c)(1) establish a
mechanism for how it will ensure that institutions
participating in the demonstration will determine whether or
not such individuals have been stabilized (as defined in
subsection (h)(5)). This mechanism shall commence before the
third day of the inpatient stay. States participating in the
demonstration project may manage the provision of services
for the stabilization of medical emergency conditions through
utilization review, authorization, or management practices,
or the application of medical necessity and appropriateness
criteria applicable to behavioral health.
(c) Eligible State Defined.--
(1) In general.--An eligible State is a State that has made
an application and has been selected pursuant to paragraphs
(2) and (3).
(2) Application.--A State seeking to participate in the
demonstration project under this section shall submit to the
Secretary, at such time and in such format as the Secretary
requires, an application that includes such information,
provisions, and assurances, as the Secretary may require.
(3) Selection.--A State shall be determined eligible for
the demonstration by the Secretary on a competitive basis
among States with applications meeting the requirements of
paragraph (1). In selecting State applications for the
demonstration project, the Secretary shall seek to achieve an
appropriate national balance in the geographic distribution
of such projects.
(d) Length of Demonstration Project.--The demonstration
project established under this section shall be conducted for
a period of 3 consecutive years.
(e) Limitations on Federal Funding.--
(1) Appropriation.--
(A) In general.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to carry out
this section, $75,000,000 for fiscal year 2011.
(B) Budget authority.--Subparagraph (A) constitutes budget
authority in advance of appropriations Act and represents the
obligation of the Federal Government to provide for the
payment of the amounts appropriated under that subparagraph.
(2) 5-year availability.--Funds appropriated under
paragraph (1) shall remain available for obligation through
December 31, 2015.
(3) Limitation on payments.--In no case may--
(A) the aggregate amount of payments made by the Secretary
to eligible States under this section exceed $75,000,000; or
(B) payments be provided by the Secretary under this
section after December 31, 2015.
(4) Funds allocated to states.--Funds shall be allocated to
eligible States on the basis of criteria, including a State's
application and the availability of funds, as determined by
the Secretary.
(5) Payments to states.--The Secretary shall pay to each
eligible State, from its allocation under paragraph (4), an
amount each quarter equal to the Federal medical assistance
percentage of expenditures in the quarter for medical
assistance described in subsection (a). As a condition of
receiving payment, a State shall collect and report
information, as determined necessary by the Secretary, for
the purposes of providing Federal oversight and conducting an
evaluation under subsection (f)(1).
(f) Evaluation and Report to Congress.--
(1) Evaluation.--The Secretary shall conduct an evaluation
of the demonstration project in order to determine the impact
on the functioning of the health and mental health service
system and on individuals enrolled in the Medicaid program
and shall include the following:
(A) An assessment of access to inpatient mental health
services under the Medicaid program; average lengths of
inpatient stays; and emergency room visits.
(B) An assessment of discharge planning by participating
hospitals.
(C) An assessment of the impact of the demonstration
project on the costs of the full range of mental health
services (including inpatient, emergency and ambulatory
care).
(D) An analysis of the percentage of consumers with
Medicaid coverage who are admitted to inpatient facilities as
a result of the demonstration project as compared to those
admitted to these same facilities through other means.
(E) A recommendation regarding whether the demonstration
project should be continued after December 31, 2013, and
expanded on a national basis.
(2) Report.--Not later than December 31, 2013, the
Secretary shall submit to Congress and make available to the
public a report on the findings of the evaluation under
paragraph (1).
(g) Waiver Authority.--
(1) In general.--The Secretary shall waive the limitation
of subdivision (B) following paragraph (28) of section
1905(a) of the Social Security Act (42 U.S.C. 1396d(a))
(relating to limitations on payments for care or services for
individuals under 65 years of age who are patients in an
institution for mental diseases) for purposes of carrying out
the demonstration project under this section.
(2) Limited other waiver authority.--The Secretary may
waive other requirements of titles XI and XIX of the Social
Security Act (including the requirements of sections
1902(a)(1) (relating to statewideness) and 1902(1)(10)(B)
(relating to comparability)) only to extent necessary to
carry out the demonstration project under this section.
(h) Definitions.--In this section:
(1) Emergency medical condition.--The term ``emergency
medical condition'' means, with respect to an individual, an
individual who expresses suicidal or homicidal thoughts or
gestures, if determined dangerous to self or others.
(2) Federal medical assistance percentage.--The term
``Federal medical assistance percentage'' has the meaning
given that term with respect to a State under section 1905(b)
of the Social Security Act (42 U.S.C. 1396d(b)).
(3) Institution for mental diseases.--The term
``institution for mental diseases'' has the meaning given to
that term in section 1905(i) of the Social Security Act (42
U.S.C. 1396d(i)).
(4) Medical assistance.--The term ``medical assistance''
has the meaning given that term in section 1905(a) of the
Social Security Act (42 U.S.C. 1396d(a)).
(5) Stabilized.--The term ``stabilized'' means, with
respect to an individual, that the emergency medical
condition no longer exists with respect to the individual and
the individual is no longer dangerous to self or others.
(6) State.--The term ``State'' has the meaning given that
term for purposes of title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).
Subtitle J--Improvements to the Medicaid and CHIP Payment and Access
Commission (MACPAC)
SEC. 2801. MACPAC ASSESSMENT OF POLICIES AFFECTING ALL
MEDICAID BENEFICIARIES.
(a) In General.--Section 1900 of the Social Security Act
(42 U.S.C. 1396) is amended--
(1) in subsection (b)--
(A) in paragraph (1)--
(i) in the paragraph heading, by inserting ``for all
states'' before ``and annual''; and
(ii) in subparagraph (A), by striking ``children's'';
(iii) in subparagraph (B), by inserting ``, the Secretary,
and States'' after ``Congress'';
(iv) in subparagraph (C), by striking ``March 1'' and
inserting ``March 15''; and
(v) in subparagraph (D), by striking ``June 1'' and
inserting ``June 15'';
(B) in paragraph (2)--
(i) in subparagraph (A)--
(I) in clause (i)--
(aa) by inserting ``the efficient provision of'' after
``expenditures for''; and
(bb) by striking ``hospital, skilled nursing facility,
physician, Federally-qualified health center, rural health
center, and other fees'' and inserting ``payments to medical,
dental, and health professionals, hospitals, residential and
long-term care providers, providers of home and community
based services, Federally-qualified health centers and rural
health clinics, managed care entities, and providers of other
covered items and services''; and
(II) in clause (iii), by inserting ``(including how such
factors and methodologies enable such beneficiaries to obtain
the services for which they are eligible, affect provider
supply, and affect providers that serve a disproportionate
share of low-income and other vulnerable populations)'' after
``beneficiaries'';
(ii) by redesignating subparagraphs (B) and (C) as
subparagraphs (F) and (H), respectively;
(iii) by inserting after subparagraph (A), the following:
``(B) Eligibility policies.--Medicaid and CHIP eligibility
policies, including a determination of the degree to which
Federal and State policies provide health care coverage to
needy populations.
``(C) Enrollment and retention processes.--Medicaid and
CHIP enrollment and retention processes, including a
determination of the degree to which Federal and State
policies encourage the enrollment of individuals who are
eligible for such programs and screen out individuals who are
ineligible, while minimizing the share of program expenses
devoted to such processes.
``(D) Coverage policies.--Medicaid and CHIP benefit and
coverage policies, including a determination of the degree to
which Federal and State policies provide access to the
services enrollees require to improve and maintain their
health and functional status.
``(E) Quality of care.--Medicaid and CHIP policies as they
relate to the quality of care provided under those programs,
including a determination of the degree to which Federal and
State policies achieve their stated goals and interact with
similar goals established by other purchasers of health care
services.'';
(iv) by inserting after subparagraph (F) (as redesignated
by clause (ii) of this subparagraph), the following:
``(G) Interactions with medicare and medicaid.--Consistent
with paragraph (11), the interaction of policies under
Medicaid and the Medicare program under title XVIII,
including with respect to how such interactions affect access
to services, payments, and dual eligible individuals.'' and
(v) in subparagraph (H) (as so redesignated), by inserting
``and preventive, acute, and long-term services and
supports'' after ``barriers'';
(C) by redesignating paragraphs (3) through (9) as
paragraphs (4) through (10), respectively;
[[Page H1976]]
(D) by inserting after paragraph (2), the following new
paragraph:
``(3) Recommendations and reports of state-specific data.--
MACPAC shall--
``(A) review national and State-specific Medicaid and CHIP
data; and
``(B) submit reports and recommendations to Congress, the
Secretary, and States based on such reviews.'';
(E) in paragraph (4), as redesignated by subparagraph (C),
by striking ``or any other problems'' and all that follows
through the period and inserting ``, as well as other factors
that adversely affect, or have the potential to adversely
affect, access to care by, or the health care status of,
Medicaid and CHIP beneficiaries. MACPAC shall include in the
annual report required under paragraph (1)(D) a description
of all such areas or problems identified with respect to the
period addressed in the report.'';
(F) in paragraph (5), as so redesignated,--
(i) in the paragraph heading, by inserting ``and
regulations'' after ``reports''; and
(ii) by striking ``If'' and inserting the following:
``(A) Certain secretarial reports.--If''; and
(iii) in the second sentence, by inserting ``and the
Secretary'' after ``appropriate committees of Congress''; and
(iv) by adding at the end the following:
``(B) Regulations.--MACPAC shall review Medicaid and CHIP
regulations and may comment through submission of a report to
the appropriate committees of Congress and the Secretary, on
any such regulations that affect access, quality, or
efficiency of health care.'';
(G) in paragraph (10), as so redesignated, by inserting ``,
and shall submit with any recommendations, a report on the
Federal and State-specific budget consequences of the
recommendations'' before the period; and
(H) by adding at the end the following:
``(11) Consultation and coordination with medpac.--
``(A) In general.--MACPAC shall consult with the Medicare
Payment Advisory Commission (in this paragraph referred to as
`MedPAC') established under section 1805 in carrying out its
duties under this section, as appropriate and particularly
with respect to the issues specified in paragraph (2) as they
relate to those Medicaid beneficiaries who are dually
eligible for Medicaid and the Medicare program under title
XVIII, adult Medicaid beneficiaries (who are not dually
eligible for Medicare), and beneficiaries under Medicare.
Responsibility for analysis of and recommendations to change
Medicare policy regarding Medicare beneficiaries, including
Medicare beneficiaries who are dually eligible for Medicare
and Medicaid, shall rest with MedPAC.
``(B) Information sharing.--MACPAC and MedPAC shall have
access to deliberations and records of the other such entity,
respectively, upon the request of the other such entity.
``(12) Consultation with states.--MACPAC shall regularly
consult with States in carrying out its duties under this
section, including with respect to developing processes for
carrying out such duties, and shall ensure that input from
States is taken into account and represented in MACPAC's
recommendations and reports.
``(13) Coordinate and consult with the federal coordinated
health care office.--MACPAC shall coordinate and consult with
the Federal Coordinated Health Care Office established under
section 2081 of the Patient Protection and Affordable Care
Act before making any recommendations regarding dual eligible
individuals.
``(14) Programmatic oversight vested in the secretary.--
MACPAC's authority to make recommendations in accordance with
this section shall not affect, or be considered to duplicate,
the Secretary's authority to carry out Federal
responsibilities with respect to Medicaid and CHIP.'';
(2) in subsection (c)(2)--
(A) by striking subparagraphs (A) and (B) and inserting the
following:
``(A) In general.--The membership of MACPAC shall include
individuals who have had direct experience as enrollees or
parents or caregivers of enrollees in Medicaid or CHIP and
individuals with national recognition for their expertise in
Federal safety net health programs, health finance and
economics, actuarial science, health plans and integrated
delivery systems, reimbursement for health care, health
information technology, and other providers of health
services, public health, and other related fields, who
provide a mix of different professions, broad geographic
representation, and a balance between urban and rural
representation.
``(B) Inclusion.--The membership of MACPAC shall include
(but not be limited to) physicians, dentists, and other
health professionals, employers, third-party payers, and
individuals with expertise in the delivery of health
services. Such membership shall also include representatives
of children, pregnant women, the elderly, individuals with
disabilities, caregivers, and dual eligible individuals,
current or former representatives of State agencies
responsible for administering Medicaid, and current or former
representatives of State agencies responsible for
administering CHIP.''.
(3) in subsection (d)(2), by inserting ``and State'' after
``Federal'';
(4) in subsection (e)(1), in the first sentence, by
inserting ``and, as a condition for receiving payments under
sections 1903(a) and 2105(a), from any State agency
responsible for administering Medicaid or CHIP,'' after
``United States''; and
(5) in subsection (f)--
(A) in the subsection heading, by striking ``Authorization
of Appropriations'' and inserting ``Funding'';
(B) in paragraph (1), by inserting ``(other than for fiscal
year 2010)'' before ``in the same manner''; and
(C) by adding at the end the following:
``(3) Funding for fiscal year 2010.--
``(A) In general.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to MACPAC to
carry out the provisions of this section for fiscal year
2010, $9,000,000.
``(B) Transfer of funds.--Notwithstanding section
2104(a)(13), from the amounts appropriated in such section
for fiscal year 2010, $2,000,000 is hereby transferred and
made available in such fiscal year to MACPAC to carry out the
provisions of this section.
``(4) Availability.--Amounts made available under
paragraphs (2) and (3) to MACPAC to carry out the provisions
of this section shall remain available until expended.''.
(b) Conforming MedPAC Amendments.--Section 1805(b) of the
Social Security Act (42 U.S.C. 1395b-6(b)), is amended--
(1) in paragraph (1)(C), by striking ``March 1 of each year
(beginning with 1998)'' and inserting ``March 15'';
(2) in paragraph (1)(D), by inserting ``, and (beginning
with 2012) containing an examination of the topics described
in paragraph (9), to the extent feasible'' before the period;
and
(3) by adding at the end the following:
``(9) Review and annual report on medicaid and commercial
trends.--The Commission shall review and report on aggregate
trends in spending, utilization, and financial performance
under the Medicaid program under title XIX and the private
market for health care services with respect to providers for
which, on an aggregate national basis, a significant portion
of revenue or services is associated with the Medicaid
program. Where appropriate, the Commission shall conduct such
review in consultation with the Medicaid and CHIP Payment and
Access Commission established under section 1900 (in this
section referred to as `MACPAC').
``(10) Coordinate and consult with the federal coordinated
health care office.--The Commission shall coordinate and
consult with the Federal Coordinated Health Care Office
established under section 2081 of the Patient Protection and
Affordable Care Act before making any recommendations
regarding dual eligible individuals.
``(11) Interaction of medicaid and medicare.--The
Commission shall consult with MACPAC in carrying out its
duties under this section, as appropriate. Responsibility for
analysis of and recommendations to change Medicare policy
regarding Medicare beneficiaries, including Medicare
beneficiaries who are dually eligible for Medicare and
Medicaid, shall rest with the Commission. Responsibility for
analysis of and recommendations to change Medicaid policy
regarding Medicaid beneficiaries, including Medicaid
beneficiaries who are dually eligible for Medicare and
Medicaid, shall rest with MACPAC.''.
Subtitle K--Protections for American Indians and Alaska Natives
SEC. 2901. SPECIAL RULES RELATING TO INDIANS.
(a) No Cost-sharing for Indians With Income at or Below 300
Percent of Poverty Enrolled in Coverage Through a State
Exchange.--For provisions prohibiting cost sharing for
Indians enrolled in any qualified health plan in the
individual market through an Exchange, see section 1402(d) of
the Patient Protection and Affordable Care Act.
(b) Payer of Last Resort.--Health programs operated by the
Indian Health Service, Indian tribes, tribal organizations,
and Urban Indian organizations (as those terms are defined in
section 4 of the Indian Health Care Improvement Act (25
U.S.C. 1603)) shall be the payer of last resort for services
provided by such Service, tribes, or organizations to
individuals eligible for services through such programs,
notwithstanding any Federal, State, or local law to the
contrary.
(c) Facilitating Enrollment of Indians Under the Express
Lane Option.--Section 1902(e)(13)(F)(ii) of the Social
Security Act (42 U.S.C. 1396a(e)(13)(F)(ii)) is amended--
(1) in the clause heading, by inserting ``and indian tribes
and tribal organizations'' after ``agencies''; and
(2) by adding at the end the following:
``(IV) The Indian Health Service, an Indian Tribe, Tribal
Organization, or Urban Indian Organization (as defined in
section 1139(c)).''.
(d) Technical Corrections.--Section 1139(c) of the Social
Security Act (42 U.S.C. 1320b-9(c)) is amended by striking
``In this section'' and inserting ``For purposes of this
section, title XIX, and title XXI''.
SEC. 2902. ELIMINATION OF SUNSET FOR REIMBURSEMENT FOR ALL
MEDICARE PART B SERVICES FURNISHED BY CERTAIN
INDIAN HOSPITALS AND CLINICS.
(a) Reimbursement for All Medicare Part B Services
Furnished by Certain Indian Hospitals and Clinics.--Section
1880(e)(1)(A) of the Social Security Act (42 U.S.C.
1395qq(e)(1)(A)) is amended by striking ``during the 5-year
period beginning on'' and inserting ``on or after''.
(b) Effective Date.--The amendments made by this section
shall apply to items or services furnished on or after
January 1, 2010.
Subtitle L--Maternal and Child Health Services
SEC. 2951. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME
VISITING PROGRAMS.
Title V of the Social Security Act (42 U.S.C. 701 et seq.)
is amended by adding at the end the following new section:
``SEC. 511. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME
VISITING PROGRAMS.
``(a) Purposes.--The purposes of this section are--
[[Page H1977]]
``(1) to strengthen and improve the programs and activities
carried out under this title;
``(2) to improve coordination of services for at risk
communities; and
``(3) to identify and provide comprehensive services to
improve outcomes for families who reside in at risk
communities.
``(b) Requirement for All States To Assess Statewide Needs
and Identify at Risk Communities.--
``(1) In general.--Not later than 6 months after the date
of enactment of this section, each State shall, as a
condition of receiving payments from an allotment for the
State under section 502 for fiscal year 2011, conduct a
statewide needs assessment (which shall be separate from the
statewide needs assessment required under section 505(a))
that identifies--
``(A) communities with concentrations of--
``(i) premature birth, low-birth weight infants, and infant
mortality, including infant death due to neglect, or other
indicators of at-risk prenatal, maternal, newborn, or child
health;
``(ii) poverty;
``(iii) crime;
``(iv) domestic violence;
``(v) high rates of high-school drop-outs;
``(vi) substance abuse;
``(vii) unemployment; or
``(viii) child maltreatment;
``(B) the quality and capacity of existing programs or
initiatives for early childhood home visitation in the State
including--
``(i) the number and types of individuals and families who
are receiving services under such programs or initiatives;
``(ii) the gaps in early childhood home visitation in the
State; and
``(iii) the extent to which such programs or initiatives
are meeting the needs of eligible families described in
subsection (k)(2); and
``(C) the State's capacity for providing substance abuse
treatment and counseling services to individuals and families
in need of such treatment or services.
``(2) Coordination with other assessments.--In conducting
the statewide needs assessment required under paragraph (1),
the State shall coordinate with, and take into account, other
appropriate needs assessments conducted by the State, as
determined by the Secretary, including the needs assessment
required under section 505(a) (both the most recently
completed assessment and any such assessment in progress),
the communitywide strategic planning and needs assessments
conducted in accordance with section 640(g)(1)(C) of the Head
Start Act, and the inventory of current unmet needs and
current community-based and prevention-focused programs and
activities to prevent child abuse and neglect, and other
family resource services operating in the State required
under section 205(3) of the Child Abuse Prevention and
Treatment Act.
``(3) Submission to the secretary.--Each State shall submit
to the Secretary, in such form and manner as the Secretary
shall require--
``(A) the results of the statewide needs assessment
required under paragraph (1); and
``(B) a description of how the State intends to address
needs identified by the assessment, particularly with respect
to communities identified under paragraph (1)(A), which may
include applying for a grant to conduct an early childhood
home visitation program in accordance with the requirements
of this section.
``(c) Grants for Early Childhood Home Visitation
Programs.--
``(1) Authority to make grants.--In addition to any other
payments made under this title to a State, the Secretary
shall make grants to eligible entities to enable the entities
to deliver services under early childhood home visitation
programs that satisfy the requirements of subsection (d) to
eligible families in order to promote improvements in
maternal and prenatal health, infant health, child health and
development, parenting related to child development outcomes,
school readiness, and the socioeconomic status of such
families, and reductions in child abuse, neglect, and
injuries.
``(2) Authority to use initial grant funds for planning or
implementation.--An eligible entity that receives a grant
under paragraph (1) may use a portion of the funds made
available to the entity during the first 6 months of the
period for which the grant is made for planning or
implementation activities to assist with the establishment of
early childhood home visitation programs that satisfy the
requirements of subsection (d).
``(3) Grant duration.--The Secretary shall determine the
period of years for which a grant is made to an eligible
entity under paragraph (1).
``(4) Technical assistance.--The Secretary shall provide an
eligible entity that receives a grant under paragraph (1)
with technical assistance in administering programs or
activities conducted in whole or in part with grant funds.
``(d) Requirements.--The requirements of this subsection
for an early childhood home visitation program conducted with
a grant made under this section are as follows:
``(1) Quantifiable, measurable improvement in benchmark
areas.--
``(A) In general.--The eligible entity establishes, subject
to the approval of the Secretary, quantifiable, measurable 3-
and 5-year benchmarks for demonstrating that the program
results in improvements for the eligible families
participating in the program in each of the following areas:
``(i) Improved maternal and newborn health.
``(ii) Prevention of child injuries, child abuse, neglect,
or maltreatment, and reduction of emergency department
visits.
``(iii) Improvement in school readiness and achievement.
``(iv) Reduction in crime or domestic violence.
``(v) Improvements in family economic self-sufficiency.
``(vi) Improvements in the coordination and referrals for
other community resources and supports.
``(B) Demonstration of improvements after 3 years.--
``(i) Report to the secretary.--Not later than 30 days
after the end of the 3rd year in which the eligible entity
conducts the program, the entity submits to the Secretary a
report demonstrating improvement in at least 4 of the areas
specified in subparagraph (A).
``(ii) Corrective action plan.--If the report submitted by
the eligible entity under clause (i) fails to demonstrate
improvement in at least 4 of the areas specified in
subparagraph (A), the entity shall develop and implement a
plan to improve outcomes in each of the areas specified in
subparagraph (A), subject to approval by the Secretary. The
plan shall include provisions for the Secretary to monitor
implementation of the plan and conduct continued oversight of
the program, including through submission by the entity of
regular reports to the Secretary.
``(iii) Technical assistance.--
``(I) In general.--The Secretary shall provide an eligible
entity required to develop and implement an improvement plan
under clause (ii) with technical assistance to develop and
implement the plan. The Secretary may provide the technical
assistance directly or through grants, contracts, or
cooperative agreements.
``(II) Advisory panel.--The Secretary shall establish an
advisory panel for purposes of obtaining recommendations
regarding the technical assistance provided to entities in
accordance with subclause (I).
``(iv) No improvement or failure to submit report.--If the
Secretary determines after a period of time specified by the
Secretary that an eligible entity implementing an improvement
plan under clause (ii) has failed to demonstrate any
improvement in the areas specified in subparagraph (A), or if
the Secretary determines that an eligible entity has failed
to submit the report required under clause (i), the Secretary
shall terminate the entity's grant and may include any
unexpended grant funds in grants made to nonprofit
organizations under subsection (h)(2)(B).
``(C) Final report.--Not later than December 31, 2015, the
eligible entity shall submit a report to the Secretary
demonstrating improvements (if any) in each of the areas
specified in subparagraph (A).
``(2) Improvements in outcomes for individual families.--
``(A) In general.--The program is designed, with respect to
an eligible family participating in the program, to result in
the participant outcomes described in subparagraph (B) that
the eligible entity identifies on the basis of an
individualized assessment of the family, are relevant for
that family.
``(B) Participant outcomes.--The participant outcomes
described in this subparagraph are the following:
``(i) Improvements in prenatal, maternal, and newborn
health, including improved pregnancy outcomes
``(ii) Improvements in child health and development,
including the prevention of child injuries and maltreatment
and improvements in cognitive, language, social-emotional,
and physical developmental indicators.
``(iii) Improvements in parenting skills.
``(iv) Improvements in school readiness and child academic
achievement.
``(v) Reductions in crime or domestic violence.
``(vi) Improvements in family economic self-sufficiency.
``(vii) Improvements in the coordination of referrals for,
and the provision of, other community resources and supports
for eligible families, consistent with State child welfare
agency training.
``(3) Core components.--The program includes the following
core components:
``(A) Service delivery model or models.--
``(i) In general.--Subject to clause (ii), the program is
conducted using 1 or more of the service delivery models
described in item (aa) or (bb) of subclause (I) or in
subclause (II) selected by the eligible entity:
``(I) The model conforms to a clear consistent home
visitation model that has been in existence for at least 3
years and is research-based, grounded in relevant
empirically-based knowledge, linked to program determined
outcomes, associated with a national organization or
institution of higher education that has comprehensive home
visitation program standards that ensure high quality service
delivery and continuous program quality improvement, and has
demonstrated significant, (and in the case of the service
delivery model described in item (aa), sustained) positive
outcomes, as described in the benchmark areas specified in
paragraph (1)(A) and the participant outcomes described in
paragraph (2)(B), when evaluated using well-designed and
rigorous--
``(aa) randomized controlled research designs, and the
evaluation results have been published in a peer-reviewed
journal; or
``(bb) quasi-experimental research designs.
``(II) The model conforms to a promising and new approach
to achieving the benchmark areas specified in paragraph
(1)(A) and the participant outcomes described in paragraph
(2)(B), has been developed or identified by a national
organization or institution of higher education, and will be
evaluated through well-designed and rigorous process.
``(ii) Majority of grant funds used for evidence-based
models.--An eligible entity shall use not more than 25
percent of the amount of the grant paid to the entity for a
fiscal year for purposes of conducting a program using the
service delivery model described in clause (i)(II).
``(iii) Criteria for evidence of effectiveness of models.--
The Secretary shall establish criteria for evidence of
effectiveness of the service delivery models and shall ensure
that the
[[Page H1978]]
process for establishing the criteria is transparent and
provides the opportunity for public comment.
``(B) Additional requirements.--
``(i) The program adheres to a clear, consistent model that
satisfies the requirements of being grounded in empirically-
based knowledge related to home visiting and linked to the
benchmark areas specified in paragraph (1)(A) and the
participant outcomes described in paragraph (2)(B) related to
the purposes of the program.
``(ii) The program employs well-trained and competent
staff, as demonstrated by education or training, such as
nurses, social workers, educators, child development
specialists, or other well-trained and competent staff, and
provides ongoing and specific training on the model being
delivered.
``(iii) The program maintains high quality supervision to
establish home visitor competencies.
``(iv) The program demonstrates strong organizational
capacity to implement the activities involved.
``(v) The program establishes appropriate linkages and
referral networks to other community resources and supports
for eligible families.
``(vi) The program monitors the fidelity of program
implementation to ensure that services are delivered pursuant
to the specified model.
``(4) Priority for serving high-risk populations.--The
eligible entity gives priority to providing services under
the program to the following:
``(A) Eligible families who reside in communities in need
of such services, as identified in the statewide needs
assessment required under subsection (b)(1)(A).
``(B) Low-income eligible families.
``(C) Eligible families who are pregnant women who have not
attained age 21.
``(D) Eligible families that have a history of child abuse
or neglect or have had interactions with child welfare
services.
``(E) Eligible families that have a history of substance
abuse or need substance abuse treatment.
``(F) Eligible families that have users of tobacco products
in the home.
``(G) Eligible families that are or have children with low
student achievement.
``(H) Eligible families with children with developmental
delays or disabilities.
``(I) Eligible families who, or that include individuals
who, are serving or formerly served in the Armed Forces,
including such families that have members of the Armed Forces
who have had multiple deployments outside of the United
States.
``(e) Application Requirements.--An eligible entity
desiring a grant under this section shall submit an
application to the Secretary for approval, in such manner as
the Secretary may require, that includes the following:
``(1) A description of the populations to be served by the
entity, including specific information regarding how the
entity will serve high risk populations described in
subsection (d)(4).
``(2) An assurance that the entity will give priority to
serving low-income eligible families and eligible families
who reside in at risk communities identified in the statewide
needs assessment required under subsection (b)(1)(A).
``(3) The service delivery model or models described in
subsection (d)(3)(A) that the entity will use under the
program and the basis for the selection of the model or
models.
``(4) A statement identifying how the selection of the
populations to be served and the service delivery model or
models that the entity will use under the program for such
populations is consistent with the results of the statewide
needs assessment conducted under subsection (b).
``(5) The quantifiable, measurable benchmarks established
by the State to demonstrate that the program contributes to
improvements in the areas specified in subsection (d)(1)(A).
``(6) An assurance that the entity will obtain and submit
documentation or other appropriate evidence from the
organization or entity that developed the service delivery
model or models used under the program to verify that the
program is implemented and services are delivered according
to the model specifications.
``(7) Assurances that the entity will establish procedures
to ensure that--
``(A) the participation of each eligible family in the
program is voluntary; and
``(B) services are provided to an eligible family in
accordance with the individual assessment for that family.
``(8) Assurances that the entity will--
``(A) submit annual reports to the Secretary regarding the
program and activities carried out under the program that
include such information and data as the Secretary shall
require; and
``(B) participate in, and cooperate with, data and
information collection necessary for the evaluation required
under subsection (g)(2) and other research and evaluation
activities carried out under subsection (h)(3).
``(9) A description of other State programs that include
home visitation services, including, if applicable to the
State, other programs carried out under this title with funds
made available from allotments under section 502(c), programs
funded under title IV, title II of the Child Abuse Prevention
and Treatment Act (relating to community-based grants for the
prevention of child abuse and neglect), and section 645A of
the Head Start Act (relating to Early Head Start programs).
``(10) Other information as required by the Secretary.
``(f) Maintenance of Effort.--Funds provided to an eligible
entity receiving a grant under this section shall supplement,
and not supplant, funds from other sources for early
childhood home visitation programs or initiatives.
``(g) Evaluation.--
``(1) Independent, expert advisory panel.--The Secretary,
in accordance with subsection (h)(1)(A), shall appoint an
independent advisory panel consisting of experts in program
evaluation and research, education, and early childhood
development--
``(A) to review, and make recommendations on, the design
and plan for the evaluation required under paragraph (2)
within 1 year after the date of enactment of this section;
``(B) to maintain and advise the Secretary regarding the
progress of the evaluation; and
``(C) to comment, if the panel so desires, on the report
submitted under paragraph (3).
``(2) Authority to conduct evaluation.--On the basis of the
recommendations of the advisory panel under paragraph (1),
the Secretary shall, by grant, contract, or interagency
agreement, conduct an evaluation of the statewide needs
assessments submitted under subsection (b) and the grants
made under subsections (c) and (h)(3)(B). The evaluation
shall include--
``(A) an analysis, on a State-by-State basis, of the
results of such assessments, including indicators of maternal
and prenatal health and infant health and mortality, and
State actions in response to the assessments; and
``(B) an assessment of--
``(i) the effect of early childhood home visitation
programs on child and parent outcomes, including with respect
to each of the benchmark areas specified in subsection
(d)(1)(A) and the participant outcomes described in
subsection (d)(2)(B);
``(ii) the effectiveness of such programs on different
populations, including the extent to which the ability of
programs to improve participant outcomes varies across
programs and populations; and
``(iii) the potential for the activities conducted under
such programs, if scaled broadly, to improve health care
practices, eliminate health disparities, and improve health
care system quality, efficiencies, and reduce costs.
``(3) Report.--Not later than March 31, 2015, the Secretary
shall submit a report to Congress on the results of the
evaluation conducted under paragraph (2) and shall make the
report publicly available.
``(h) Other Provisions.--
``(1) Intra-agency collaboration.--The Secretary shall
ensure that the Maternal and Child Health Bureau and the
Administration for Children and Families collaborate with
respect to carrying out this section, including with respect
to--
``(A) reviewing and analyzing the statewide needs
assessments required under subsection (b), the awarding and
oversight of grants awarded under this section, the
establishment of the advisory panels required under
subsections (d)(1)(B)(iii)(II) and (g)(1), and the evaluation
and report required under subsection (g); and
``(B) consulting with other Federal agencies with
responsibility for administering or evaluating programs that
serve eligible families to coordinate and collaborate with
respect to research related to such programs and families,
including the Office of the Assistant Secretary for Planning
and Evaluation of the Department of Health and Human
Services, the Centers for Disease Control and Prevention, the
National Institute of Child Health and Human Development of
the National Institutes of Health, the Office of Juvenile
Justice and Delinquency Prevention of the Department of
Justice, and the Institute of Education Sciences of the
Department of Education.
``(2) Grants to eligible entities that are not states.--
``(A) Indian tribes, tribal organizations, or urban indian
organizations.--The Secretary shall specify requirements for
eligible entities that are Indian Tribes (or a consortium of
Indian Tribes), Tribal Organizations, or Urban Indian
Organizations to apply for and conduct an early childhood
home visitation program with a grant under this section. Such
requirements shall, to the greatest extent practicable, be
consistent with the requirements applicable to eligible
entities that are States and shall require an Indian Tribe
(or consortium), Tribal Organization, or Urban Indian
Organization to--
``(i) conduct a needs assessment similar to the assessment
required for all States under subsection (b); and
``(ii) establish quantifiable, measurable 3- and 5-year
benchmarks consistent with subsection (d)(1)(A).
``(B) Nonprofit organizations.--If, as of the beginning of
fiscal year 2012, a State has not applied or been approved
for a grant under this section, the Secretary may use amounts
appropriated under paragraph (1) of subsection (j) that are
available for expenditure under paragraph (3) of that
subsection to make a grant to an eligible entity that is a
nonprofit organization described in subsection (k)(1)(B) to
conduct an early childhood home visitation program in the
State. The Secretary shall specify the requirements for such
an organization to apply for and conduct the program which
shall, to the greatest extent practicable, be consistent with
the requirements applicable to eligible entities that are
States and shall require the organization to--
``(i) carry out the program based on the needs assessment
conducted by the State under subsection (b); and
``(ii) establish quantifiable, measurable 3- and 5-year
benchmarks consistent with subsection (d)(1)(A).
``(3) Research and other evaluation activities.--
``(A) In general.--The Secretary shall carry out a
continuous program of research and evaluation activities in
order to increase knowledge about the implementation and
effectiveness of home visiting programs, using random
assignment designs to the maximum extent feasible. The
Secretary may carry out such activities directly, or through
grants, cooperative agreements, or contracts.
[[Page H1979]]
``(B) Requirements.--The Secretary shall ensure that--
``(i) evaluation of a specific program or project is
conducted by persons or individuals not directly involved in
the operation of such program or project; and
``(ii) the conduct of research and evaluation activities
includes consultation with independent researchers, State
officials, and developers and providers of home visiting
programs on topics including research design and
administrative data matching.
``(4) Report and recommendation.--Not later than December
31, 2015, the Secretary shall submit a report to Congress
regarding the programs conducted with grants under this
section. The report required under this paragraph shall
include--
``(A) information regarding the extent to which eligible
entities receiving grants under this section demonstrated
improvements in each of the areas specified in subsection
(d)(1)(A);
``(B) information regarding any technical assistance
provided under subsection (d)(1)(B)(iii)(I), including the
type of any such assistance provided; and
``(C) recommendations for such legislative or
administrative action as the Secretary determines
appropriate.
``(i) Application of Other Provisions of Title.--
``(1) In general.--Except as provided in paragraph (2), the
other provisions of this title shall not apply to a grant
made under this section.
``(2) Exceptions.--The following provisions of this title
shall apply to a grant made under this section to the same
extent and in the same manner as such provisions apply to
allotments made under section 502(c):
``(A) Section 504(b)(6) (relating to prohibition on
payments to excluded individuals and entities).
``(B) Section 504(c) (relating to the use of funds for the
purchase of technical assistance).
``(C) Section 504(d) (relating to a limitation on
administrative expenditures).
``(D) Section 506 (relating to reports and audits), but
only to the extent determined by the Secretary to be
appropriate for grants made under this section.
``(E) Section 507 (relating to penalties for false
statements).
``(F) Section 508 (relating to nondiscrimination).
``(G) Section 509(a) (relating to the administration of the
grant program).
``(j) Appropriations.--
``(1) In general.--Out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the
Secretary to carry out this section--
``(A) $100,000,000 for fiscal year 2010;
``(B) $250,000,000 for fiscal year 2011;
``(C) $350,000,000 for fiscal year 2012;
``(D) $400,000,000 for fiscal year 2013; and
``(E) $400,000,000 for fiscal year 2014.
``(2) Reservations.--Of the amount appropriated under this
subsection for a fiscal year, the Secretary shall reserve--
``(A) 3 percent of such amount for purposes of making
grants to eligible entities that are Indian Tribes (or a
consortium of Indian Tribes), Tribal Organizations, or Urban
Indian Organizations; and
``(B) 3 percent of such amount for purposes of carrying out
subsections (d)(1)(B)(iii), (g), and (h)(3).
``(3) Availability.--Funds made available to an eligible
entity under this section for a fiscal year shall remain
available for expenditure by the eligible entity through the
end of the second succeeding fiscal year after award. Any
funds that are not expended by the eligible entity during the
period in which the funds are available under the preceding
sentence may be used for grants to nonprofit organizations
under subsection (h)(2)(B).
``(k) Definitions.--In this section:
``(1) Eligible entity.--
``(A) In general.--The term `eligible entity' means a
State, an Indian Tribe, Tribal Organization, or Urban Indian
Organization, Puerto Rico, Guam, the Virgin Islands, the
Northern Mariana Islands, and American Samoa.
``(B) Nonprofit organizations.--Only for purposes of
awarding grants under subsection (h)(2)(B), such term shall
include a nonprofit organization with an established record
of providing early childhood home visitation programs or
initiatives in a State or several States.
``(2) Eligible family.--The term `eligible family' means--
``(A) a woman who is pregnant, and the father of the child
if the father is available; or
``(B) a parent or primary caregiver of a child, including
grandparents or other relatives of the child, and foster
parents, who are serving as the child's primary caregiver
from birth to kindergarten entry, and including a
noncustodial parent who has an ongoing relationship with, and
at times provides physical care for, the child.
``(3) Indian tribe; tribal organization.--The terms `Indian
Tribe' and `Tribal Organization', and `Urban Indian
Organization' have the meanings given such terms in section 4
of the Indian Health Care Improvement Act.''.
SEC. 2952. SUPPORT, EDUCATION, AND RESEARCH FOR POSTPARTUM
DEPRESSION.
(a) Research on Postpartum Conditions.--
(1) Expansion and intensification of activities.--The
Secretary of Health and Human Services (in this subsection
and subsection (c) referred to as the ``Secretary'') is
encouraged to continue activities on postpartum depression or
postpartum psychosis (in this subsection and subsection (c)
referred to as ``postpartum conditions''), including research
to expand the understanding of the causes of, and treatments
for, postpartum conditions. Activities under this paragraph
shall include conducting and supporting the following:
(A) Basic research concerning the etiology and causes of
the conditions.
(B) Epidemiological studies to address the frequency and
natural history of the conditions and the differences among
racial and ethnic groups with respect to the conditions.
(C) The development of improved screening and diagnostic
techniques.
(D) Clinical research for the development and evaluation of
new treatments.
(E) Information and education programs for health care
professionals and the public, which may include a coordinated
national campaign to increase the awareness and knowledge of
postpartum conditions. Activities under such a national
campaign may--
(i) include public service announcements through
television, radio, and other means; and
(ii) focus on--
(I) raising awareness about screening;
(II) educating new mothers and their families about
postpartum conditions to promote earlier diagnosis and
treatment; and
(III) ensuring that such education includes complete
information concerning postpartum conditions, including its
symptoms, methods of coping with the illness, and treatment
resources.
(2) Sense of congress regarding longitudinal study of
relative mental health consequences for women of resolving a
pregnancy.--
(A) Sense of congress.--It is the sense of Congress that
the Director of the National Institute of Mental Health may
conduct a nationally representative longitudinal study
(during the period of fiscal years 2010 through 2019) of the
relative mental health consequences for women of resolving a
pregnancy (intended and unintended) in various ways,
including carrying the pregnancy to term and parenting the
child, carrying the pregnancy to term and placing the child
for adoption, miscarriage, and having an abortion. This study
may assess the incidence, timing, magnitude, and duration of
the immediate and long-term mental health consequences
(positive or negative) of these pregnancy outcomes.
(B) Report.--Subject to the completion of the study under
subsection (a), beginning not later than 5 years after the
date of the enactment of this Act, and periodically
thereafter for the duration of the study, such Director may
prepare and submit to the Congress reports on the findings of
the study.
(b) Grants To Provide Services to Individuals With a
Postpartum Condition and Their Families.--Title V of the
Social Security Act (42 U.S.C. 701 et seq.), as amended by
section 2951, is amended by adding at the end the following
new section:
``SEC. 512. SERVICES TO INDIVIDUALS WITH A POSTPARTUM
CONDITION AND THEIR FAMILIES.
``(a) In General.--In addition to any other payments made
under this title to a State, the Secretary may make grants to
eligible entities for projects for the establishment,
operation, and coordination of effective and cost-efficient
systems for the delivery of essential services to individuals
with or at risk for postpartum conditions and their families.
``(b) Certain Activities.--To the extent practicable and
appropriate, the Secretary shall ensure that projects funded
under subsection (a) provide education and services with
respect to the diagnosis and management of postpartum
conditions for individuals with or at risk for postpartum
conditions and their families. The Secretary may allow such
projects to include the following:
``(1) Delivering or enhancing outpatient and home-based
health and support services, including case management and
comprehensive treatment services.
``(2) Delivering or enhancing inpatient care management
services that ensure the well-being of the mother and family
and the future development of the infant.
``(3) Improving the quality, availability, and organization
of health care and support services (including transportation
services, attendant care, homemaker services, day or respite
care, and providing counseling on financial assistance and
insurance).
``(4) Providing education about postpartum conditions to
promote earlier diagnosis and treatment. Such education may
include--
``(A) providing complete information on postpartum
conditions, symptoms, methods of coping with the illness, and
treatment resources; and
``(B) in the case of a grantee that is a State, hospital,
or birthing facility--
``(i) providing education to new mothers and fathers, and
other family members as appropriate, concerning postpartum
conditions before new mothers leave the health facility; and
``(ii) ensuring that training programs regarding such
education are carried out at the health facility.
``(c) Integration With Other Programs.--To the extent
practicable and appropriate, the Secretary may integrate the
grant program under this section with other grant programs
carried out by the Secretary, including the program under
section 330 of the Public Health Service Act.
``(d) Requirements.--The Secretary shall establish
requirements for grants made under this section that include
a limit on the amount of grants funds that may be used for
administration, accounting, reporting, or program oversight
functions and a requirement for each eligible entity that
receives a grant to submit, for each grant period, a report
to the Secretary that describes how grant funds were used
during such period.
``(e) Technical Assistance.--The Secretary may provide
technical assistance to entities seeking a grant under this
section in order to assist such entities in complying with
the requirements of this section.
``(f) Application of Other Provisions of Title.--
[[Page H1980]]
``(1) In general.--Except as provided in paragraph (2), the
other provisions of this title shall not apply to a grant
made under this section.
``(2) Exceptions.--The following provisions of this title
shall apply to a grant made under this section to the same
extent and in the same manner as such provisions apply to
allotments made under section 502(c):
``(A) Section 504(b)(6) (relating to prohibition on
payments to excluded individuals and entities).
``(B) Section 504(c) (relating to the use of funds for the
purchase of technical assistance).
``(C) Section 504(d) (relating to a limitation on
administrative expenditures).
``(D) Section 506 (relating to reports and audits), but
only to the extent determined by the Secretary to be
appropriate for grants made under this section.
``(E) Section 507 (relating to penalties for false
statements).
``(F) Section 508 (relating to nondiscrimination).
``(G) Section 509(a) (relating to the administration of the
grant program).
``(g) Definitions.--In this section:
``(1) The term `eligible entity'--
``(A) means a public or nonprofit private entity; and
``(B) includes a State or local government, public-private
partnership, recipient of a grant under section 330H of the
Public Health Service Act (relating to the Healthy Start
Initiative), public or nonprofit private hospital, community-
based organization, hospice, ambulatory care facility,
community health center, migrant health center, public
housing primary care center, or homeless health center.
``(2) The term `postpartum condition' means postpartum
depression or postpartum psychosis.''.
(c) General Provisions.--
(1) Authorization of appropriations.--To carry out this
section and the amendment made by subsection (b), there are
authorized to be appropriated, in addition to such other sums
as may be available for such purpose--
(A) $3,000,000 for fiscal year 2010; and
(B) such sums as may be necessary for fiscal years 2011 and
2012.
(2) Report by the secretary.--
(A) Study.--The Secretary shall conduct a study on the
benefits of screening for postpartum conditions.
(B) Report.--Not later than 2 years after the date of the
enactment of this Act, the Secretary shall complete the study
required by subparagraph (A) and submit a report to the
Congress on the results of such study.
SEC. 2953. PERSONAL RESPONSIBILITY EDUCATION.
Title V of the Social Security Act (42 U.S.C. 701 et seq.),
as amended by sections 2951 and 2952(c), is amended by adding
at the end the following:
``SEC. 513. PERSONAL RESPONSIBILITY EDUCATION.
``(a) Allotments to States.--
``(1) Amount.--
``(A) In general.--For the purpose described in subsection
(b), subject to the succeeding provisions of this section,
for each of fiscal years 2010 through 2014, the Secretary
shall allot to each State an amount equal to the product of--
``(i) the amount appropriated under subsection (f) for the
fiscal year and available for allotments to States after the
application of subsection (c); and
``(ii) the State youth population percentage determined
under paragraph (2).
``(B) Minimum allotment.--
``(i) In general.--Each State allotment under this
paragraph for a fiscal year shall be at least $250,000.
``(ii) Pro rata adjustments.--The Secretary shall adjust on
a pro rata basis the amount of the State allotments
determined under this paragraph for a fiscal year to the
extent necessary to comply with clause (i).
``(C) Application required to access allotments.--
``(i) In general.--A State shall not be paid from its
allotment for a fiscal year unless the State submits an
application to the Secretary for the fiscal year and the
Secretary approves the application (or requires changes to
the application that the State satisfies) and meets such
additional requirements as the Secretary may specify.
``(ii) Requirements.--The State application shall contain
an assurance that the State has complied with the
requirements of this section in preparing and submitting the
application and shall include the following as well as such
additional information as the Secretary may require:
``(I) Based on data from the Centers for Disease Control
and Prevention National Center for Health Statistics, the
most recent pregnancy rates for the State for youth ages 10
to 14 and youth ages 15 to 19 for which data are available,
the most recent birth rates for such youth populations in the
State for which data are available, and trends in those rates
for the most recently preceding 5-year period for which such
data are available.
``(II) State-established goals for reducing the pregnancy
rates and birth rates for such youth populations.
``(III) A description of the State's plan for using the
State allotments provided under this section to achieve such
goals, especially among youth populations that are the most
high-risk or vulnerable for pregnancies or otherwise have
special circumstances, including youth in foster care,
homeless youth, youth with HIV/AIDS, pregnant youth who are
under 21 years of age, mothers who are under 21 years of age,
and youth residing in areas with high birth rates for youth.
``(2) State youth population percentage.--
``(A) In general.--For purposes of paragraph (1)(A)(ii),
the State youth population percentage is, with respect to a
State, the proportion (expressed as a percentage) of--
``(i) the number of individuals who have attained age 10
but not attained age 20 in the State; to
``(ii) the number of such individuals in all States.
``(B) Determination of number of youth.--The number of
individuals described in clauses (i) and (ii) of subparagraph
(A) in a State shall be determined on the basis of the most
recent Bureau of the Census data.
``(3) Availability of state allotments.--Subject to
paragraph (4)(A), amounts allotted to a State pursuant to
this subsection for a fiscal year shall remain available for
expenditure by the State through the end of the second
succeeding fiscal year.
``(4) Authority to award grants from state allotments to
local organizations and entities in nonparticipating
states.--
``(A) Grants from unexpended allotments.--If a State does
not submit an application under this section for fiscal year
2010 or 2011, the State shall no longer be eligible to submit
an application to receive funds from the amounts allotted for
the State for each of fiscal years 2010 through 2014 and such
amounts shall be used by the Secretary to award grants under
this paragraph for each of fiscal years 2012 through 2014.
The Secretary also shall use any amounts from the allotments
of States that submit applications under this section for a
fiscal year that remain unexpended as of the end of the
period in which the allotments are available for expenditure
under paragraph (3) for awarding grants under this paragraph.
``(B) 3-year grants.--
``(i) In general.--The Secretary shall solicit applications
to award 3-year grants in each of fiscal years 2012, 2013,
and 2014 to local organizations and entities to conduct,
consistent with subsection (b), programs and activities in
States that do not submit an application for an allotment
under this section for fiscal year 2010 or 2011.
``(ii) Faith-based organizations or consortia.--The
Secretary may solicit and award grants under this paragraph
to faith-based organizations or consortia.
``(C) Evaluation.--An organization or entity awarded a
grant under this paragraph shall agree to participate in a
rigorous Federal evaluation.
``(5) Maintenance of effort.--No payment shall be made to a
State from the allotment determined for the State under this
subsection or to a local organization or entity awarded a
grant under paragraph (4), if the expenditure of non-federal
funds by the State, organization, or entity for activities,
programs, or initiatives for which amounts from allotments
and grants under this subsection may be expended is less than
the amount expended by the State, organization, or entity for
such programs or initiatives for fiscal year 2009.
``(6) Data collection and reporting.--A State or local
organization or entity receiving funds under this section
shall cooperate with such requirements relating to the
collection of data and information and reporting on outcomes
regarding the programs and activities carried out with such
funds, as the Secretary shall specify.
``(b) Purpose.--
``(1) In general.--The purpose of an allotment under
subsection (a)(1) to a State is to enable the State (or, in
the case of grants made under subsection (a)(4)(B), to enable
a local organization or entity) to carry out personal
responsibility education programs consistent with this
subsection.
``(2) Personal responsibility education programs.--
``(A) In general.--In this section, the term `personal
responsibility education program' means a program that is
designed to educate adolescents on--
``(i) both abstinence and contraception for the prevention
of pregnancy and sexually transmitted infections, including
HIV/AIDS, consistent with the requirements of subparagraph
(B); and
``(ii) at least 3 of the adulthood preparation subjects
described in subparagraph (C).
``(B) Requirements.--The requirements of this subparagraph
are the following:
``(i) The program replicates evidence-based effective
programs or substantially incorporates elements of effective
programs that have been proven on the basis of rigorous
scientific research to change behavior, which means delaying
sexual activity, increasing condom or contraceptive use for
sexually active youth, or reducing pregnancy among youth.
``(ii) The program is medically-accurate and complete.
``(iii) The program includes activities to educate youth
who are sexually active regarding responsible sexual behavior
with respect to both abstinence and the use of contraception.
``(iv) The program places substantial emphasis on both
abstinence and contraception for the prevention of pregnancy
among youth and sexually transmitted infections.
``(v) The program provides age-appropriate information and
activities.
``(vi) The information and activities carried out under the
program are provided in the cultural context that is most
appropriate for individuals in the particular population
group to which they are directed.
``(C) Adulthood preparation subjects.--The adulthood
preparation subjects described in this subparagraph are the
following:
``(i) Healthy relationships, such as positive self-esteem
and relationship dynamics, friendships, dating, romantic
involvement, marriage, and family interactions.
``(ii) Adolescent development, such as the development of
healthy attitudes and values about
[[Page H1981]]
adolescent growth and development, body image, racial and
ethnic diversity, and other related subjects.
``(iii) Financial literacy.
``(iv) Parent-child communication.
``(v) Educational and career success, such as developing
skills for employment preparation, job seeking, independent
living, financial self-sufficiency, and workplace
productivity.
``(vi) Healthy life skills, such as goal-setting, decision
making, negotiation, communication and interpersonal skills,
and stress management.
``(c) Reservations of Funds.--
``(1) Grants to implement innovative strategies.--From the
amount appropriated under subsection (f) for the fiscal year,
the Secretary shall reserve $10,000,000 of such amount for
purposes of awarding grants to entities to implement
innovative youth pregnancy prevention strategies and target
services to high-risk, vulnerable, and culturally under-
represented youth populations, including youth in foster
care, homeless youth, youth with HIV/AIDS, pregnant women who
are under 21 years of age and their partners, mothers who are
under 21 years of age and their partners, and youth residing
in areas with high birth rates for youth. An entity awarded a
grant under this paragraph shall agree to participate in a
rigorous Federal evaluation of the activities carried out
with grant funds.
``(2) Other reservations.--From the amount appropriated
under subsection (f) for the fiscal year that remains after
the application of paragraph (1), the Secretary shall reserve
the following amounts:
``(A) Grants for indian tribes or tribal organizations.--
The Secretary shall reserve 5 percent of such remainder for
purposes of awarding grants to Indian tribes and tribal
organizations in such manner, and subject to such
requirements, as the Secretary, in consultation with Indian
tribes and tribal organizations, determines appropriate.
``(B) Secretarial responsibilities.--
``(i) Reservation of funds.--The Secretary shall reserve 10
percent of such remainder for expenditures by the Secretary
for the activities described in clauses (ii) and (iii).
``(ii) Program support.--The Secretary shall provide,
directly or through a competitive grant process, research,
training and technical assistance, including dissemination of
research and information regarding effective and promising
practices, providing consultation and resources on a broad
array of teen pregnancy prevention strategies, including
abstinence and contraception, and developing resources and
materials to support the activities of recipients of grants
and other State, tribal, and community organizations working
to reduce teen pregnancy. In carrying out such functions, the
Secretary shall collaborate with a variety of entities that
have expertise in the prevention of teen pregnancy, HIV and
sexually transmitted infections, healthy relationships,
financial literacy, and other topics addressed through the
personal responsibility education programs.
``(iii) Evaluation.--The Secretary shall evaluate the
programs and activities carried out with funds made available
through allotments or grants under this section.
``(d) Administration.--
``(1) In general.--The Secretary shall administer this
section through the Assistant Secretary for the
Administration for Children and Families within the
Department of Health and Human Services.
``(2) Application of other provisions of title.--
``(A) In general.--Except as provided in subparagraph (B),
the other provisions of this title shall not apply to
allotments or grants made under this section.
``(B) Exceptions.--The following provisions of this title
shall apply to allotments and grants made under this section
to the same extent and in the same manner as such provisions
apply to allotments made under section 502(c):
``(i) Section 504(b)(6) (relating to prohibition on
payments to excluded individuals and entities).
``(ii) Section 504(c) (relating to the use of funds for the
purchase of technical assistance).
``(iii) Section 504(d) (relating to a limitation on
administrative expenditures).
``(iv) Section 506 (relating to reports and audits), but
only to the extent determined by the Secretary to be
appropriate for grants made under this section.
``(v) Section 507 (relating to penalties for false
statements).
``(vi) Section 508 (relating to nondiscrimination).
``(e) Definitions.--In this section:
``(1) Age-appropriate.--The term `age-appropriate', with
respect to the information in pregnancy prevention, means
topics, messages, and teaching methods suitable to particular
ages or age groups of children and adolescents, based on
developing cognitive, emotional, and behavioral capacity
typical for the age or age group.
``(2) Medically accurate and complete.--The term `medically
accurate and complete' means verified or supported by the
weight of research conducted in compliance with accepted
scientific methods and--
``(A) published in peer-reviewed journals, where
applicable; or
``(B) comprising information that leading professional
organizations and agencies with relevant expertise in the
field recognize as accurate, objective, and complete.
``(3) Indian tribes; tribal organizations.--The terms
`Indian tribe' and `Tribal organization' have the meanings
given such terms in section 4 of the Indian Health Care
Improvement Act (25 U.S.C. 1603)).
``(4) Youth.--The term `youth' means an individual who has
attained age 10 but has not attained age 20.
``(f) Appropriation.--For the purpose of carrying out this
section, there is appropriated, out of any money in the
Treasury not otherwise appropriated, $75,000,000 for each of
fiscal years 2010 through 2014. Amounts appropriated under
this subsection shall remain available until expended.''.
SEC. 2954. RESTORATION OF FUNDING FOR ABSTINENCE EDUCATION.
Section 510 of the Social Security Act (42 U.S.C. 710) is
amended--
(1) in subsection (a), by striking ``fiscal year 1998 and
each subsequent fiscal year'' and inserting ``each of fiscal
years 2010 through 2014''; and
(2) in subsection (d)--
(A) in the first sentence, by striking ``1998 through
2003'' and inserting ``2010 through 2014''; and
(B) in the second sentence, by inserting ``(except that
such appropriation shall be made on the date of enactment of
the Patient Protection and Affordable Care Act in the case of
fiscal year 2010)'' before the period.
SEC. 2955. INCLUSION OF INFORMATION ABOUT THE IMPORTANCE OF
HAVING A HEALTH CARE POWER OF ATTORNEY IN
TRANSITION PLANNING FOR CHILDREN AGING OUT OF
FOSTER CARE AND INDEPENDENT LIVING PROGRAMS.
(a) Transition Planning.--Section 475(5)(H) of the Social
Security Act (42 U.S.C. 675(5)(H)) is amended by inserting
``includes information about the importance of designating
another individual to make health care treatment decisions on
behalf of the child if the child becomes unable to
participate in such decisions and the child does not have, or
does not want, a relative who would otherwise be authorized
under State law to make such decisions, and provides the
child with the option to execute a health care power of
attorney, health care proxy, or other similar document
recognized under State law,'' after ``employment services,''.
(b) Independent Living Education.--Section 477(b)(3) of
such Act (42 U.S.C. 677(b)(3)) is amended by adding at the
end the following:
``(K) A certification by the chief executive officer of the
State that the State will ensure that an adolescent
participating in the program under this section are provided
with education about the importance of designating another
individual to make health care treatment decisions on behalf
of the adolescent if the adolescent becomes unable to
participate in such decisions and the adolescent does not
have, or does not want, a relative who would otherwise be
authorized under State law to make such decisions, whether a
health care power of attorney, health care proxy, or other
similar document is recognized under State law, and how to
execute such a document if the adolescent wants to do so.''.
(c) Health Oversight and Coordination Plan.--Section
422(b)(15)(A) of such Act (42 U.S.C. 622(b)(15)(A)) is
amended--
(1) in clause (v), by striking ``and'' at the end; and
(2) by adding at the end the following:
``(vii) steps to ensure that the components of the
transition plan development process required under section
475(5)(H) that relate to the health care needs of children
aging out of foster care, including the requirements to
include options for health insurance, information about a
health care power of attorney, health care proxy, or other
similar document recognized under State law, and to provide
the child with the option to execute such a document, are
met; and''.
(d) Effective Date.--The amendments made by this section
take effect on October 1, 2010.
TITLE III--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE
Subtitle A--Transforming the Health Care Delivery System
PART I--LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE MEDICARE PROGRAM
SEC. 3001. HOSPITAL VALUE-BASED PURCHASING PROGRAM.
(a) Program.--
(1) In general.--Section 1886 of the Social Security Act
(42 U.S.C. 1395ww), as amended by section 4102(a) of the
HITECH Act (Public Law 111-5), is amended by adding at the
end the following new subsection:
``(o) Hospital Value-Based Purchasing Program.--
``(1) Establishment.--
``(A) In general.--Subject to the succeeding provisions of
this subsection, the Secretary shall establish a hospital
value-based purchasing program (in this subsection referred
to as the `Program') under which value-based incentive
payments are made in a fiscal year to hospitals that meet the
performance standards under paragraph (3) for the performance
period for such fiscal year (as established under paragraph
(4)).
``(B) Program to begin in fiscal year 2013.--The Program
shall apply to payments for discharges occurring on or after
October 1, 2012.
``(C) Applicability of program to hospitals.--
``(i) In general.--For purposes of this subsection, subject
to clause (ii), the term `hospital' means a subsection (d)
hospital (as defined in subsection (d)(1)(B)).
``(ii) Exclusions.--The term `hospital' shall not include,
with respect to a fiscal year, a hospital--
``(I) that is subject to the payment reduction under
subsection (b)(3)(B)(viii)(I) for such fiscal year;
``(II) for which, during the performance period for such
fiscal year, the Secretary has cited deficiencies that pose
immediate jeopardy to the health or safety of patients;
``(III) for which there are not a minimum number (as
determined by the Secretary) of measures that apply to the
hospital for the performance period for such fiscal year; or
[[Page H1982]]
``(IV) for which there are not a minimum number (as
determined by the Secretary) of cases for the measures that
apply to the hospital for the performance period for such
fiscal year.
``(iii) Independent analysis.--For purposes of determining
the minimum numbers under subclauses (III) and (IV) of clause
(ii), the Secretary shall have conducted an independent
analysis of what numbers are appropriate.
``(iv) Exemption.--In the case of a hospital that is paid
under section 1814(b)(3), the Secretary may exempt such
hospital from the application of this subsection if the State
which is paid under such section submits an annual report to
the Secretary describing how a similar program in the State
for a participating hospital or hospitals achieves or
surpasses the measured results in terms of patient health
outcomes and cost savings established under this subsection.
``(2) Measures.--
``(A) In general.--The Secretary shall select measures for
purposes of the Program. Such measures shall be selected from
the measures specified under subsection (b)(3)(B)(viii).
``(B) Requirements.--
``(i) For fiscal year 2013.--For value-based incentive
payments made with respect to discharges occurring during
fiscal year 2013, the Secretary shall ensure the following:
``(I) Conditions or procedures.--Measures are selected
under subparagraph (A) that cover at least the following 5
specific conditions or procedures:
``(aa) Acute myocardial infarction (AMI).
``(bb) Heart failure.
``(cc) Pneumonia.
``(dd) Surgeries, as measured by the Surgical Care
Improvement Project (formerly referred to as `Surgical
Infection Prevention' for discharges occurring before July
2006).
``(ee) Healthcare-associated infections, as measured by the
prevention metrics and targets established in the HHS Action
Plan to Prevent Healthcare-Associated Infections (or any
successor plan) of the Department of Health and Human
Services.
``(II) HCAHPS.--Measures selected under subparagraph (A)
shall be related to the Hospital Consumer Assessment of
Healthcare Providers and Systems survey (HCAHPS).
``(ii) Inclusion of efficiency measures.--For value-based
incentive payments made with respect to discharges occurring
during fiscal year 2014 or a subsequent fiscal year, the
Secretary shall ensure that measures selected under
subparagraph (A) include efficiency measures, including
measures of `Medicare spending per beneficiary'. Such
measures shall be adjusted for factors such as age, sex,
race, severity of illness, and other factors that the
Secretary determines appropriate.
``(C) Limitations.--
``(i) Time requirement for prior reporting and notice.--The
Secretary may not select a measure under subparagraph (A) for
use under the Program with respect to a performance period
for a fiscal year (as established under paragraph (4)) unless
such measure has been specified under subsection
(b)(3)(B)(viii) and included on the Hospital Compare Internet
website for at least 1 year prior to the beginning of such
performance period.
``(ii) Measure not applicable unless hospital furnishes
services appropriate to the measure.--A measure selected
under subparagraph (A) shall not apply to a hospital if such
hospital does not furnish services appropriate to such
measure.
``(D) Replacing measures.--Subclause (VI) of subsection
(b)(3)(B)(viii) shall apply to measures selected under
subparagraph (A) in the same manner as such subclause applies
to measures selected under such subsection.
``(3) Performance standards.--
``(A) Establishment.--The Secretary shall establish
performance standards with respect to measures selected under
paragraph (2) for a performance period for a fiscal year (as
established under paragraph (4)).
``(B) Achievement and improvement.--The performance
standards established under subparagraph (A) shall include
levels of achievement and improvement.
``(C) Timing.--The Secretary shall establish and announce
the performance standards under subparagraph (A) not later
than 60 days prior to the beginning of the performance period
for the fiscal year involved.
``(D) Considerations in establishing standards.--In
establishing performance standards with respect to measures
under this paragraph, the Secretary shall take into account
appropriate factors, such as--
``(i) practical experience with the measures involved,
including whether a significant proportion of hospitals
failed to meet the performance standard during previous
performance periods;
``(ii) historical performance standards;
``(iii) improvement rates; and
``(iv) the opportunity for continued improvement.
``(4) Performance period.--For purposes of the Program, the
Secretary shall establish the performance period for a fiscal
year. Such performance period shall begin and end prior to
the beginning of such fiscal year.
``(5) Hospital performance score.--
``(A) In general.--Subject to subparagraph (B), the
Secretary shall develop a methodology for assessing the total
performance of each hospital based on performance standards
with respect to the measures selected under paragraph (2) for
a performance period (as established under paragraph (4)).
Using such methodology, the Secretary shall provide for an
assessment (in this subsection referred to as the `hospital
performance score') for each hospital for each performance
period.
``(B) Application.--
``(i) Appropriate distribution.--The Secretary shall ensure
that the application of the methodology developed under
subparagraph (A) results in an appropriate distribution of
value-based incentive payments under paragraph (6) among
hospitals achieving different levels of hospital performance
scores, with hospitals achieving the highest hospital
performance scores receiving the largest value-based
incentive payments.
``(ii) Higher of achievement or improvement.--The
methodology developed under subparagraph (A) shall provide
that the hospital performance score is determined using the
higher of its achievement or improvement score for each
measure.
``(iii) Weights.--The methodology developed under
subparagraph (A) shall provide for the assignment of weights
for categories of measures as the Secretary determines
appropriate.
``(iv) No minimum performance standard.--The Secretary
shall not set a minimum performance standard in determining
the hospital performance score for any hospital.
``(v) Reflection of measures applicable to the hospital.--
The hospital performance score for a hospital shall reflect
the measures that apply to the hospital.
``(6) Calculation of value-based incentive payments.--
``(A) In general.--In the case of a hospital that the
Secretary determines meets (or exceeds) the performance
standards under paragraph (3) for the performance period for
a fiscal year (as established under paragraph (4)), the
Secretary shall increase the base operating DRG payment
amount (as defined in paragraph (7)(D)), as determined after
application of paragraph (7)(B)(i), for a hospital for each
discharge occurring in such fiscal year by the value-based
incentive payment amount.
``(B) Value-based incentive payment amount.--The value-
based incentive payment amount for each discharge of a
hospital in a fiscal year shall be equal to the product of--
``(i) the base operating DRG payment amount (as defined in
paragraph (7)(D)) for the discharge for the hospital for such
fiscal year; and
``(ii) the value-based incentive payment percentage
specified under subparagraph (C) for the hospital for such
fiscal year.
``(C) Value-based incentive payment percentage.--
``(i) In general.--The Secretary shall specify a value-
based incentive payment percentage for a hospital for a
fiscal year.
``(ii) Requirements.--In specifying the value-based
incentive payment percentage for each hospital for a fiscal
year under clause (i), the Secretary shall ensure that--
``(I) such percentage is based on the hospital performance
score of the hospital under paragraph (5); and
``(II) the total amount of value-based incentive payments
under this paragraph to all hospitals in such fiscal year is
equal to the total amount available for value-based incentive
payments for such fiscal year under paragraph (7)(A), as
estimated by the Secretary.
``(7) Funding for value-based incentive payments.--
``(A) Amount.--The total amount available for value-based
incentive payments under paragraph (6) for all hospitals for
a fiscal year shall be equal to the total amount of reduced
payments for all hospitals under subparagraph (B) for such
fiscal year, as estimated by the Secretary.
``(B) Adjustment to payments.--
``(i) In general.--The Secretary shall reduce the base
operating DRG payment amount (as defined in subparagraph (D))
for a hospital for each discharge in a fiscal year (beginning
with fiscal year 2013) by an amount equal to the applicable
percent (as defined in subparagraph (C)) of the base
operating DRG payment amount for the discharge for the
hospital for such fiscal year. The Secretary shall make such
reductions for all hospitals in the fiscal year involved,
regardless of whether or not the hospital has been determined
by the Secretary to have earned a value-based incentive
payment under paragraph (6) for such fiscal year.
``(ii) No effect on other payments.--Payments described in
items (aa) and (bb) of subparagraph (D)(i)(II) for a hospital
shall be determined as if this subsection had not been
enacted.
``(C) Applicable percent defined.--For purposes of
subparagraph (B), the term `applicable percent' means--
``(i) with respect to fiscal year 2013, 1.0 percent;
``(ii) with respect to fiscal year 2014, 1.25 percent;
``(iii) with respect to fiscal year 2015, 1.5 percent;
``(iv) with respect to fiscal year 2016, 1.75 percent; and
``(v) with respect to fiscal year 2017 and succeeding
fiscal years, 2 percent.
``(D) Base operating drg payment amount defined.--
``(i) In general.--Except as provided in clause (ii), in
this subsection, the term `base operating DRG payment amount'
means, with respect to a hospital for a fiscal year--
``(I) the payment amount that would otherwise be made under
subsection (d) (determined without regard to subsection (q))
for a discharge if this subsection did not apply; reduced by
``(II) any portion of such payment amount that is
attributable to--
``(aa) payments under paragraphs (5)(A), (5)(B), (5)(F),
and (12) of subsection (d); and
``(bb) such other payments under subsection (d) determined
appropriate by the Secretary.
``(ii) Special rules for certain hospitals.--
``(I) Sole community hospitals and medicare-dependent,
small rural hospitals.--In the case of a medicare-dependent,
small rural hospital (with respect to discharges occurring
during fiscal year 2012 and 2013) or a sole community
hospital, in applying subparagraph (A)(i), the payment amount
that would otherwise be made under subsection (d) shall be
determined without regard to subparagraphs (I)
[[Page H1983]]
and (L) of subsection (b)(3) and subparagraphs (D) and (G) of
subsection (d)(5).
``(II) Hospitals paid under section 1814.--In the case of a
hospital that is paid under section 1814(b)(3), the term
`base operating DRG payment amount' means the payment amount
under such section.
``(8) Announcement of net result of adjustments.--Under the
Program, the Secretary shall, not later than 60 days prior to
the fiscal year involved, inform each hospital of the
adjustments to payments to the hospital for discharges
occurring in such fiscal year under paragraphs (6) and
(7)(B)(i).
``(9) No effect in subsequent fiscal years.--The value-
based incentive payment under paragraph (6) and the payment
reduction under paragraph (7)(B)(i) shall each apply only
with respect to the fiscal year involved, and the Secretary
shall not take into account such value-based incentive
payment or payment reduction in making payments to a hospital
under this section in a subsequent fiscal year.
``(10) Public reporting.--
``(A) Hospital specific information.--
``(i) In general.--The Secretary shall make information
available to the public regarding the performance of
individual hospitals under the Program, including--
``(I) the performance of the hospital with respect to each
measure that applies to the hospital;
``(II) the performance of the hospital with respect to each
condition or procedure; and
``(III) the hospital performance score assessing the total
performance of the hospital.
``(ii) Opportunity to review and submit corrections.--The
Secretary shall ensure that a hospital has the opportunity to
review, and submit corrections for, the information to be
made public with respect to the hospital under clause (i)
prior to such information being made public.
``(iii) Website.--Such information shall be posted on the
Hospital Compare Internet website in an easily understandable
format.
``(B) Aggregate information.--The Secretary shall
periodically post on the Hospital Compare Internet website
aggregate information on the Program, including--
``(i) the number of hospitals receiving value-based
incentive payments under paragraph (6) and the range and
total amount of such value-based incentive payments; and
``(ii) the number of hospitals receiving less than the
maximum value-based incentive payment available to the
hospital for the fiscal year involved and the range and
amount of such payments.
``(11) Implementation.--
``(A) Appeals.--The Secretary shall establish a process by
which hospitals may appeal the calculation of a hospital's
performance assessment with respect to the performance
standards established under paragraph (3)(A) and the hospital
performance score under paragraph (5). The Secretary shall
ensure that such process provides for resolution of such
appeals in a timely manner.
``(B) Limitation on review.--Except as provided in
subparagraph (A), there shall be no administrative or
judicial review under section 1869, section 1878, or
otherwise of the following:
``(i) The methodology used to determine the amount of the
value-based incentive payment under paragraph (6) and the
determination of such amount.
``(ii) The determination of the amount of funding available
for such value-based incentive payments under paragraph
(7)(A) and the payment reduction under paragraph (7)(B)(i).
``(iii) The establishment of the performance standards
under paragraph (3) and the performance period under
paragraph (4).
``(iv) The measures specified under subsection
(b)(3)(B)(viii) and the measures selected under paragraph
(2).
``(v) The methodology developed under paragraph (5) that is
used to calculate hospital performance scores and the
calculation of such scores.
``(vi) The validation methodology specified in subsection
(b)(3)(B)(viii)(XI).
``(C) Consultation with small hospitals.--The Secretary
shall consult with small rural and urban hospitals on the
application of the Program to such hospitals.
``(12) Promulgation of regulations.--The Secretary shall
promulgate regulations to carry out the Program, including
the selection of measures under paragraph (2), the
methodology developed under paragraph (5) that is used to
calculate hospital performance scores, and the methodology
used to determine the amount of value-based incentive
payments under paragraph (6).''.
(2) Amendments for reporting of hospital quality
information.--Section 1886(b)(3)(B)(viii) of the Social
Security Act (42 U.S.C. 1395ww(b)(3)(B)(viii)) is amended--
(A) in subclause (II), by adding at the end the following
sentence: ``The Secretary may require hospitals to submit
data on measures that are not used for the determination of
value-based incentive payments under subsection (o).'';
(B) in subclause (V), by striking ``beginning with fiscal
year 2008'' and inserting ``for fiscal years 2008 through
2012'';
(C) in subclause (VII), in the first sentence, by striking
``data submitted'' and inserting ``information regarding
measures submitted''; and
(D) by adding at the end the following new subclauses:
``(VIII) Effective for payments beginning with fiscal year
2013, with respect to quality measures for outcomes of care,
the Secretary shall provide for such risk adjustment as the
Secretary determines to be appropriate to maintain incentives
for hospitals to treat patients with severe illnesses or
conditions.
``(IX)(aa) Subject to item (bb), effective for payments
beginning with fiscal year 2013, each measure specified by
the Secretary under this clause shall be endorsed by the
entity with a contract under section 1890(a).
``(bb) In the case of a specified area or medical topic
determined appropriate by the Secretary for which a feasible
and practical measure has not been endorsed by the entity
with a contract under section 1890(a), the Secretary may
specify a measure that is not so endorsed as long as due
consideration is given to measures that have been endorsed or
adopted by a consensus organization identified by the
Secretary.
``(X) To the extent practicable, the Secretary shall, with
input from consensus organizations and other stakeholders,
take steps to ensure that the measures specified by the
Secretary under this clause are coordinated and aligned with
quality measures applicable to--
``(aa) physicians under section 1848(k); and
``(bb) other providers of services and suppliers under this
title.
``(XI) The Secretary shall establish a process to validate
measures specified under this clause as appropriate. Such
process shall include the auditing of a number of randomly
selected hospitals sufficient to ensure validity of the
reporting program under this clause as a whole and shall
provide a hospital with an opportunity to appeal the
validation of measures reported by such hospital.''.
(3) Website improvements.--Section 1886(b)(3)(B) of the
Social Security Act (42 U.S.C. 1395ww(b)(3)(B)), as amended
by section 4102(b) of the HITECH Act (Public Law 111-5), is
amended by adding at the end the following new clause:
``(x)(I) The Secretary shall develop standard Internet
website reports tailored to meet the needs of various
stakeholders such as hospitals, patients, researchers, and
policymakers. The Secretary shall seek input from such
stakeholders in determining the type of information that is
useful and the formats that best facilitate the use of the
information.
``(II) The Secretary shall modify the Hospital Compare
Internet website to make the use and navigation of that
website readily available to individuals accessing it.''.
(4) GAO study and report.--
(A) Study.--The Comptroller General of the United States
shall conduct a study on the performance of the hospital
value-based purchasing program established under section
1886(o) of the Social Security Act, as added by paragraph
(1). Such study shall include an analysis of the impact of
such program on--
(i) the quality of care furnished to Medicare
beneficiaries, including diverse Medicare beneficiary
populations (such as diverse in terms of race, ethnicity, and
socioeconomic status);
(ii) expenditures under the Medicare program, including any
reduced expenditures under Part A of title XVIII of such Act
that are attributable to the improvement in the delivery of
inpatient hospital services by reason of such hospital value-
based purchasing program;
(iii) the quality performance among safety net hospitals
and any barriers such hospitals face in meeting the
performance standards applicable under such hospital value-
based purchasing program; and
(iv) the quality performance among small rural and small
urban hospitals and any barriers such hospitals face in
meeting the performance standards applicable under such
hospital value-based purchasing program.
(B) Reports.--
(i) Interim report.--Not later than October 1, 2015, the
Comptroller General of the United States shall submit to
Congress an interim report containing the results of the
study conducted under subparagraph (A), together with
recommendations for such legislation and administrative
action as the Comptroller General determines appropriate.
(ii) Final report.--Not later than July 1, 2017, the
Comptroller General of the United States shall submit to
Congress a report containing the results of the study
conducted under subparagraph (A), together with
recommendations for such legislation and administrative
action as the Comptroller General determines appropriate.
(5) HHS study and report.--
(A) Study.--The Secretary of Health and Human Services
shall conduct a study on the performance of the hospital
value-based purchasing program established under section
1886(o) of the Social Security Act, as added by paragraph
(1). Such study shall include an analysis--
(i) of ways to improve the hospital value-based purchasing
program and ways to address any unintended consequences that
may occur as a result of such program;
(ii) of whether the hospital value-based purchasing program
resulted in lower spending under the Medicare program under
title XVIII of such Act or other financial savings to
hospitals;
(iii) the appropriateness of the Medicare program sharing
in any savings generated through the hospital value-based
purchasing program; and
(iv) any other area determined appropriate by the
Secretary.
(B) Report.--Not later than January 1, 2016, the Secretary
of Health and Human Services shall submit to Congress a
report containing the results of the study conducted under
subparagraph (A), together with recommendations for such
legislation and administrative action as the Secretary
determines appropriate.
(b) Value-Based Purchasing Demonstration Programs.--
(1) Value-based purchasing demonstration program for
inpatient critical access hospitals.--
(A) Establishment.--
(i) In general.--Not later than 2 years after the date of
enactment of this Act, the Secretary of Health and Human
Services (in this subsection referred to as the
``Secretary'') shall establish a demonstration program under
which
[[Page H1984]]
the Secretary establishes a value-based purchasing program
under the Medicare program under title XVIII of the Social
Security Act for critical access hospitals (as defined in
paragraph (1) of section 1861(mm) of such Act (42 U.S.C.
1395x(mm))) with respect to inpatient critical access
hospital services (as defined in paragraph (2) of such
section) in order to test innovative methods of measuring and
rewarding quality and efficient health care furnished by such
hospitals.
(ii) Duration.--The demonstration program under this
paragraph shall be conducted for a 3-year period.
(iii) Sites.--The Secretary shall conduct the demonstration
program under this paragraph at an appropriate number (as
determined by the Secretary) of critical access hospitals.
The Secretary shall ensure that such hospitals are
representative of the spectrum of such hospitals that
participate in the Medicare program.
(B) Waiver authority.--The Secretary may waive such
requirements of titles XI and XVIII of the Social Security
Act as may be necessary to carry out the demonstration
program under this paragraph.
(C) Budget neutrality requirement.--In conducting the
demonstration program under this section, the Secretary shall
ensure that the aggregate payments made by the Secretary do
not exceed the amount which the Secretary would have paid if
the demonstration program under this section was not
implemented.
(D) Report.--Not later than 18 months after the completion
of the demonstration program under this paragraph, the
Secretary shall submit to Congress a report on the
demonstration program together with--
(i) recommendations on the establishment of a permanent
value-based purchasing program under the Medicare program for
critical access hospitals with respect to inpatient critical
access hospital services; and
(ii) recommendations for such other legislation and
administrative action as the Secretary determines
appropriate.
(2) Value-based purchasing demonstration program for
hospitals excluded from hospital value-based purchasing
program as a result of insufficient numbers of measures and
cases.--
(A) Establishment.--
(i) In general.--Not later than 2 years after the date of
enactment of this Act, the Secretary shall establish a
demonstration program under which the Secretary establishes a
value-based purchasing program under the Medicare program
under title XVIII of the Social Security Act for applicable
hospitals (as defined in clause (ii)) with respect to
inpatient hospital services (as defined in section 1861(b) of
the Social Security Act (42 U.S.C. 1395x(b))) in order to
test innovative methods of measuring and rewarding quality
and efficient health care furnished by such hospitals.
(ii) Applicable hospital defined.--For purposes of this
paragraph, the term ``applicable hospital'' means a hospital
described in subclause (III) or (IV) of section
1886(o)(1)(C)(ii) of the Social Security Act, as added by
subsection (a)(1).
(iii) Duration.--The demonstration program under this
paragraph shall be conducted for a 3-year period.
(iv) Sites.--The Secretary shall conduct the demonstration
program under this paragraph at an appropriate number (as
determined by the Secretary) of applicable hospitals. The
Secretary shall ensure that such hospitals are representative
of the spectrum of such hospitals that participate in the
Medicare program.
(B) Waiver authority.--The Secretary may waive such
requirements of titles XI and XVIII of the Social Security
Act as may be necessary to carry out the demonstration
program under this paragraph.
(C) Budget neutrality requirement.--In conducting the
demonstration program under this section, the Secretary shall
ensure that the aggregate payments made by the Secretary do
not exceed the amount which the Secretary would have paid if
the demonstration program under this section was not
implemented.
(D) Report.--Not later than 18 months after the completion
of the demonstration program under this paragraph, the
Secretary shall submit to Congress a report on the
demonstration program together with--
(i) recommendations on the establishment of a permanent
value-based purchasing program under the Medicare program for
applicable hospitals with respect to inpatient hospital
services; and
(ii) recommendations for such other legislation and
administrative action as the Secretary determines
appropriate.
SEC. 3002. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING
SYSTEM.
(a) Extension.--Section 1848(m) of the Social Security Act
(42 U.S.C. 1395w-4(m)) is amended--
(1) in paragraph (1)--
(A) in subparagraph (A), in the matter preceding clause
(i), by striking ``2010'' and inserting ``2014''; and
(B) in subparagraph (B)--
(i) in clause (i), by striking ``and'' at the end;
(ii) in clause (ii), by striking the period at the end and
inserting a semicolon; and
(iii) by adding at the end the following new clauses:
``(iii) for 2011, 1.0 percent; and
``(iv) for 2012, 2013, and 2014, 0.5 percent.'';
(2) in paragraph (3)--
(A) in subparagraph (A), in the matter preceding clause
(i), by inserting ``(or, for purposes of subsection (a)(8),
for the quality reporting period for the year)'' after
``reporting period''; and
(B) in subparagraph (C)(i), by inserting ``, or, for
purposes of subsection (a)(8), for a quality reporting period
for the year'' after ``(a)(5), for a reporting period for a
year'';
(3) in paragraph (5)(E)(iv), by striking ``subsection
(a)(5)(A)'' and inserting ``paragraphs (5)(A) and (8)(A) of
subsection (a)''; and
(4) in paragraph (6)(C)--
(A) in clause (i)(II), by striking ``, 2009, 2010, and
2011'' and inserting ``and subsequent years''; and
(B) in clause (iii)--
(i) by inserting ``(a)(8)'' after ``(a)(5)''; and
(ii) by striking ``under subparagraph (D)(iii) of such
subsection'' and inserting ``under subsection (a)(5)(D)(iii)
or the quality reporting period under subsection
(a)(8)(D)(iii), respectively''.
(b) Incentive Payment Adjustment for Quality Reporting.--
Section 1848(a) of the Social Security Act (42 U.S.C. 1395w-
4(a)) is amended by adding at the end the following new
paragraph:
``(8) Incentives for quality reporting.--
``(A) Adjustment.--
``(i) In general.--With respect to covered professional
services furnished by an eligible professional during 2015 or
any subsequent year, if the eligible professional does not
satisfactorily submit data on quality measures for covered
professional services for the quality reporting period for
the year (as determined under subsection (m)(3)(A)), the fee
schedule amount for such services furnished by such
professional during the year (including the fee schedule
amount for purposes of determining a payment based on such
amount) shall be equal to the applicable percent of the fee
schedule amount that would otherwise apply to such services
under this subsection (determined after application of
paragraphs (3), (5), and (7), but without regard to this
paragraph).
``(ii) Applicable percent.--For purposes of clause (i), the
term `applicable percent' means--
``(I) for 2015, 98.5 percent; and
``(II) for 2016 and each subsequent year, 98 percent.
``(B) Application.--
``(i) Physician reporting system rules.--Paragraphs (5),
(6), and (8) of subsection (k) shall apply for purposes of
this paragraph in the same manner as they apply for purposes
of such subsection.
``(ii) Incentive payment validation rules.--Clauses (ii)
and (iii) of subsection (m)(5)(D) shall apply for purposes of
this paragraph in a similar manner as they apply for purposes
of such subsection.
``(C) Definitions.--For purposes of this paragraph:
``(i) Eligible professional; covered professional
services.--The terms `eligible professional' and `covered
professional services' have the meanings given such terms in
subsection (k)(3).
``(ii) Physician reporting system.--The term `physician
reporting system' means the system established under
subsection (k).
``(iii) Quality reporting period.--The term `quality
reporting period' means, with respect to a year, a period
specified by the Secretary.''.
(c) Maintenance of Certification Programs.--
(1) In general.--Section 1848(k)(4) of the Social Security
Act (42 U.S.C. 1395w-4(k)(4)) is amended by inserting ``or
through a Maintenance of Certification program operated by a
specialty body of the American Board of Medical Specialties
that meets the criteria for such a registry'' after
``Database)''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply for years after 2010.
(d) Integration of Physician Quality Reporting and EHR
Reporting.--Section 1848(m) of the Social Security Act (42
U.S.C. 1395w-4(m)) is amended by adding at the end the
following new paragraph:
``(7) Integration of physician quality reporting and ehr
reporting.--Not later than January 1, 2012, the Secretary
shall develop a plan to integrate reporting on quality
measures under this subsection with reporting requirements
under subsection (o) relating to the meaningful use of
electronic health records. Such integration shall consist of
the following:
``(A) The selection of measures, the reporting of which
would both demonstrate--
``(i) meaningful use of an electronic health record for
purposes of subsection (o); and
``(ii) quality of care furnished to an individual.
``(B) Such other activities as specified by the
Secretary.''.
(e) Feedback.--Section 1848(m)(5) of the Social Security
Act (42 U.S.C. 1395w-4(m)(5)) is amended by adding at the end
the following new subparagraph:
``(H) Feedback.--The Secretary shall provide timely
feedback to eligible professionals on the performance of the
eligible professional with respect to satisfactorily
submitting data on quality measures under this subsection.''.
(f) Appeals.--Such section is further amended--
(1) in subparagraph (E), by striking ``There shall'' and
inserting ``Except as provided in subparagraph (I), there
shall''; and
(2) by adding at the end the following new subparagraph:
``(I) Informal appeals process.--The Secretary shall, by
not later than January 1, 2011, establish and have in place
an informal process for eligible professionals to seek a
review of the determination that an eligible professional did
not satisfactorily submit data on quality measures under this
subsection.''.
SEC. 3003. IMPROVEMENTS TO THE PHYSICIAN FEEDBACK PROGRAM.
(a) In General.--Section 1848(n) of the Social Security Act
(42 U.S.C. 1395w-4(n)) is amended--
(1) in paragraph (1)--
(A) in subparagraph (A)--
(i) by striking ``general.--The Secretary'' and inserting
``general.--
[[Page H1985]]
``(i) Establishment.--The Secretary'';
(ii) in clause (i), as added by clause (i), by striking
``the `Program')'' and all that follows through the period at
the end of the second sentence and inserting ``the
`Program').''; and
(iii) by adding at the end the following new clauses:
``(ii) Reports on resources.--The Secretary shall use
claims data under this title (and may use other data) to
provide confidential reports to physicians (and, as
determined appropriate by the Secretary, to groups of
physicians) that measure the resources involved in furnishing
care to individuals under this title.
``(iii) Inclusion of certain information.--If determined
appropriate by the Secretary, the Secretary may include
information on the quality of care furnished to individuals
under this title by the physician (or group of physicians) in
such reports.''; and
(B) in subparagraph (B), by striking ``subparagraph (A)''
and inserting ``subparagraph (A)(ii)'';
(2) in paragraph (4)--
(A) in the heading, by inserting ``initial'' after
``focus''; and
(B) in the matter preceding subparagraph (A), by inserting
``initial'' after ``focus the'';
(3) in paragraph (6), by adding at the end the following
new sentence: ``For adjustments for reports on utilization
under paragraph (9), see subparagraph (D) of such
paragraph.''; and
(4) by adding at the end the following new paragraphs:
``(9) Reports on utilization.--
``(A) Development of episode grouper.--
``(i) In general.--The Secretary shall develop an episode
grouper that combines separate but clinically related items
and services into an episode of care for an individual, as
appropriate.
``(ii) Timeline for development.--The episode grouper
described in subparagraph (A) shall be developed by not later
than January 1, 2012.
``(iii) Public availability.--The Secretary shall make the
details of the episode grouper described in subparagraph (A)
available to the public.
``(iv) Endorsement.--The Secretary shall seek endorsement
of the episode grouper described in subparagraph (A) by the
entity with a contract under section 1890(a).
``(B) Reports on utilization.--Effective beginning with
2012, the Secretary shall provide reports to physicians that
compare, as determined appropriate by the Secretary, patterns
of resource use of the individual physician to such patterns
of other physicians.
``(C) Analysis of data.--The Secretary shall, for purposes
of preparing reports under this paragraph, establish
methodologies as appropriate, such as to--
``(i) attribute episodes of care, in whole or in part, to
physicians;
``(ii) identify appropriate physicians for purposes of
comparison under subparagraph (B); and
``(iii) aggregate episodes of care attributed to a
physician under clause (i) into a composite measure per
individual.
``(D) Data adjustment.--In preparing reports under this
paragraph, the Secretary shall make appropriate adjustments,
including adjustments--
``(i) to account for differences in socioeconomic and
demographic characteristics, ethnicity, and health status of
individuals (such as to recognize that less healthy
individuals may require more intensive interventions); and
``(ii) to eliminate the effect of geographic adjustments in
payment rates (as described in subsection (e)).
``(E) Public availability of methodology.--The Secretary
shall make available to the public--
``(i) the methodologies established under subparagraph (C);
``(ii) information regarding any adjustments made to data
under subparagraph (D); and
``(iii) aggregate reports with respect to physicians.
``(F) Definition of physician.--In this paragraph:
``(i) In general.--The term `physician' has the meaning
given that term in section 1861(r)(1).
``(ii) Treatment of groups.--Such term includes, as the
Secretary determines appropriate, a group of physicians.
``(G) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of the establishment of the methodology
under subparagraph (C), including the determination of an
episode of care under such methodology.
``(10) Coordination with other value-based purchasing
reforms.--The Secretary shall coordinate the Program with the
value-based payment modifier established under subsection (p)
and, as the Secretary determines appropriate, other similar
provisions of this title.''.
(b) Conforming Amendment.--Section 1890(b) of the Social
Security Act (42 U.S.C. 1395aaa(b)) is amended by adding at
the end the following new paragraph:
``(6) Review and endorsement of episode grouper under the
physician feedback program.--The entity shall provide for the
review and, as appropriate, the endorsement of the episode
grouper developed by the Secretary under section
1848(n)(9)(A). Such review shall be conducted on an expedited
basis.''.
SEC. 3004. QUALITY REPORTING FOR LONG-TERM CARE HOSPITALS,
INPATIENT REHABILITATION HOSPITALS, AND HOSPICE
PROGRAMS.
(a) Long-term Care Hospitals.--Section 1886(m) of the
Social Security Act (42 U.S.C. 1395ww(m)), as amended by
section 3401(c), is amended by adding at the end the
following new paragraph:
``(5) Quality reporting.--
``(A) Reduction in update for failure to report.--
``(i) In general.--Under the system described in paragraph
(1), for rate year 2014 and each subsequent rate year, in the
case of a long-term care hospital that does not submit data
to the Secretary in accordance with subparagraph (C) with
respect to such a rate year, any annual update to a standard
Federal rate for discharges for the hospital during the rate
year, and after application of paragraph (3), shall be
reduced by 2 percentage points.
``(ii) Special rule.--The application of this subparagraph
may result in such annual update being less than 0.0 for a
rate year, and may result in payment rates under the system
described in paragraph (1) for a rate year being less than
such payment rates for the preceding rate year.
``(B) Noncumulative application.--Any reduction under
subparagraph (A) shall apply only with respect to the rate
year involved and the Secretary shall not take into account
such reduction in computing the payment amount under the
system described in paragraph (1) for a subsequent rate year.
``(C) Submission of quality data.--For rate year 2014 and
each subsequent rate year, each long-term care hospital shall
submit to the Secretary data on quality measures specified
under subparagraph (D). Such data shall be submitted in a
form and manner, and at a time, specified by the Secretary
for purposes of this subparagraph.
``(D) Quality measures.--
``(i) In general.--Subject to clause (ii), any measure
specified by the Secretary under this subparagraph must have
been endorsed by the entity with a contract under section
1890(a).
``(ii) Exception.--In the case of a specified area or
medical topic determined appropriate by the Secretary for
which a feasible and practical measure has not been endorsed
by the entity with a contract under section 1890(a), the
Secretary may specify a measure that is not so endorsed as
long as due consideration is given to measures that have been
endorsed or adopted by a consensus organization identified by
the Secretary.
``(iii) Time frame.--Not later than October 1, 2012, the
Secretary shall publish the measures selected under this
subparagraph that will be applicable with respect to rate
year 2014.
``(E) Public availability of data submitted.--The Secretary
shall establish procedures for making data submitted under
subparagraph (C) available to the public. Such procedures
shall ensure that a long-term care hospital has the
opportunity to review the data that is to be made public with
respect to the hospital prior to such data being made public.
The Secretary shall report quality measures that relate to
services furnished in inpatient settings in long-term care
hospitals on the Internet website of the Centers for Medicare
& Medicaid Services.''.
(b) Inpatient Rehabilitation Hospitals.--Section 1886(j) of
the Social Security Act (42 U.S.C. 1395ww(j)) is amended--
(1) by redesignating paragraph (7) as paragraph (8); and
(2) by inserting after paragraph (6) the following new
paragraph:
``(7) Quality reporting.--
``(A) Reduction in update for failure to report.--
``(i) In general.--For purposes of fiscal year 2014 and
each subsequent fiscal year, in the case of a rehabilitation
facility that does not submit data to the Secretary in
accordance with subparagraph (C) with respect to such a
fiscal year, after determining the increase factor described
in paragraph (3)(C), and after application of paragraph
(3)(D), the Secretary shall reduce such increase factor for
payments for discharges occurring during such fiscal year by
2 percentage points.
``(ii) Special rule.--The application of this subparagraph
may result in the increase factor described in paragraph
(3)(C) being less than 0.0 for a fiscal year, and may result
in payment rates under this subsection for a fiscal year
being less than such payment rates for the preceding fiscal
year.
``(B) Noncumulative application.--Any reduction under
subparagraph (A) shall apply only with respect to the fiscal
year involved and the Secretary shall not take into account
such reduction in computing the payment amount under this
subsection for a subsequent fiscal year.
``(C) Submission of quality data.--For fiscal year 2014 and
each subsequent rate year, each rehabilitation facility shall
submit to the Secretary data on quality measures specified
under subparagraph (D). Such data shall be submitted in a
form and manner, and at a time, specified by the Secretary
for purposes of this subparagraph.
``(D) Quality measures.--
``(i) In general.--Subject to clause (ii), any measure
specified by the Secretary under this subparagraph must have
been endorsed by the entity with a contract under section
1890(a).
``(ii) Exception.--In the case of a specified area or
medical topic determined appropriate by the Secretary for
which a feasible and practical measure has not been endorsed
by the entity with a contract under section 1890(a), the
Secretary may specify a measure that is not so endorsed as
long as due consideration is given to measures that have been
endorsed or adopted by a consensus organization identified by
the Secretary.
``(iii) Time frame.--Not later than October 1, 2012, the
Secretary shall publish the measures selected under this
subparagraph that will be applicable with respect to fiscal
year 2014.
``(E) Public availability of data submitted.--The Secretary
shall establish procedures for making data submitted under
subparagraph (C) available to the public. Such procedures
shall ensure that a rehabilitation facility
[[Page H1986]]
has the opportunity to review the data that is to be made
public with respect to the facility prior to such data being
made public. The Secretary shall report quality measures that
relate to services furnished in inpatient settings in
rehabilitation facilities on the Internet website of the
Centers for Medicare & Medicaid Services.''.
(c) Hospice Programs.--Section 1814(i) of the Social
Security Act (42 U.S.C. 1395f(i)) is amended--
(1) by redesignating paragraph (5) as paragraph (6); and
(2) by inserting after paragraph (4) the following new
paragraph:
``(5) Quality reporting.--
``(A) Reduction in update for failure to report.--
``(i) In general.--For purposes of fiscal year 2014 and
each subsequent fiscal year, in the case of a hospice program
that does not submit data to the Secretary in accordance with
subparagraph (C) with respect to such a fiscal year, after
determining the market basket percentage increase under
paragraph (1)(C)(ii)(VII) or paragraph (1)(C)(iii), as
applicable, and after application of paragraph (1)(C)(iv),
with respect to the fiscal year, the Secretary shall reduce
such market basket percentage increase by 2 percentage
points.
``(ii) Special rule.--The application of this subparagraph
may result in the market basket percentage increase under
paragraph (1)(C)(ii)(VII) or paragraph (1)(C)(iii), as
applicable, being less than 0.0 for a fiscal year, and may
result in payment rates under this subsection for a fiscal
year being less than such payment rates for the preceding
fiscal year.
``(B) Noncumulative application.--Any reduction under
subparagraph (A) shall apply only with respect to the fiscal
year involved and the Secretary shall not take into account
such reduction in computing the payment amount under this
subsection for a subsequent fiscal year.
``(C) Submission of quality data.--For fiscal year 2014 and
each subsequent fiscal year, each hospice program shall
submit to the Secretary data on quality measures specified
under subparagraph (D). Such data shall be submitted in a
form and manner, and at a time, specified by the Secretary
for purposes of this subparagraph.
``(D) Quality measures.--
``(i) In general.--Subject to clause (ii), any measure
specified by the Secretary under this subparagraph must have
been endorsed by the entity with a contract under section
1890(a).
``(ii) Exception.--In the case of a specified area or
medical topic determined appropriate by the Secretary for
which a feasible and practical measure has not been endorsed
by the entity with a contract under section 1890(a), the
Secretary may specify a measure that is not so endorsed as
long as due consideration is given to measures that have been
endorsed or adopted by a consensus organization identified by
the Secretary.
``(iii) Time frame.--Not later than October 1, 2012, the
Secretary shall publish the measures selected under this
subparagraph that will be applicable with respect to fiscal
year 2014.
``(E) Public availability of data submitted.--The Secretary
shall establish procedures for making data submitted under
subparagraph (C) available to the public. Such procedures
shall ensure that a hospice program has the opportunity to
review the data that is to be made public with respect to the
hospice program prior to such data being made public. The
Secretary shall report quality measures that relate to
hospice care provided by hospice programs on the Internet
website of the Centers for Medicare & Medicaid Services.''.
SEC. 3005. QUALITY REPORTING FOR PPS-EXEMPT CANCER HOSPITALS.
Section 1866 of the Social Security Act (42 U.S.C. 1395cc)
is amended--
(1) in subsection (a)(1)--
(A) in subparagraph (U), by striking ``and'' at the end;
(B) in subparagraph (V), by striking the period at the end
and inserting ``, and''; and
(C) by adding at the end the following new subparagraph:
``(W) in the case of a hospital described in section
1886(d)(1)(B)(v), to report quality data to the Secretary in
accordance with subsection (k).''; and
(2) by adding at the end the following new subsection:
``(k) Quality Reporting by Cancer Hospitals.--
``(1) In general.--For purposes of fiscal year 2014 and
each subsequent fiscal year, a hospital described in section
1886(d)(1)(B)(v) shall submit data to the Secretary in
accordance with paragraph (2) with respect to such a fiscal
year.
``(2) Submission of quality data.--For fiscal year 2014 and
each subsequent fiscal year, each hospital described in such
section shall submit to the Secretary data on quality
measures specified under paragraph (3). Such data shall be
submitted in a form and manner, and at a time, specified by
the Secretary for purposes of this subparagraph.
``(3) Quality measures.--
``(A) In general.--Subject to subparagraph (B), any measure
specified by the Secretary under this paragraph must have
been endorsed by the entity with a contract under section
1890(a).
``(B) Exception.--In the case of a specified area or
medical topic determined appropriate by the Secretary for
which a feasible and practical measure has not been endorsed
by the entity with a contract under section 1890(a), the
Secretary may specify a measure that is not so endorsed as
long as due consideration is given to measures that have been
endorsed or adopted by a consensus organization identified by
the Secretary.
``(C) Time frame.--Not later than October 1, 2012, the
Secretary shall publish the measures selected under this
paragraph that will be applicable with respect to fiscal year
2014.
``(4) Public availability of data submitted.--The Secretary
shall establish procedures for making data submitted under
paragraph (4) available to the public. Such procedures shall
ensure that a hospital described in section 1886(d)(1)(B)(v)
has the opportunity to review the data that is to be made
public with respect to the hospital prior to such data being
made public. The Secretary shall report quality measures of
process, structure, outcome, patients' perspective on care,
efficiency, and costs of care that relate to services
furnished in such hospitals on the Internet website of the
Centers for Medicare & Medicaid Services.''.
SEC. 3006. PLANS FOR A VALUE-BASED PURCHASING PROGRAM FOR
SKILLED NURSING FACILITIES AND HOME HEALTH
AGENCIES.
(a) Skilled Nursing Facilities.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
develop a plan to implement a value-based purchasing program
for payments under the Medicare program under title XVIII of
the Social Security Act for skilled nursing facilities (as
defined in section 1819(a) of such Act (42 U.S.C. 1395i-
3(a))).
(2) Details.--In developing the plan under paragraph (1),
the Secretary shall consider the following issues:
(A) The ongoing development, selection, and modification
process for measures (including under section 1890 of the
Social Security Act (42 U.S.C. 1395aaa) and section 1890A
such Act, as added by section 3014), to the extent feasible
and practicable, of all dimensions of quality and efficiency
in skilled nursing facilities.
(i) In general.--Subject to clause (ii), any measure
specified by the Secretary under subparagraph (A)(iii) must
have been endorsed by the entity with a contract under
section 1890(a).
(ii) Exception.--In the case of a specified area or medical
topic determined appropriate by the Secretary for which a
feasible and practical measure has not been endorsed by the
entity with a contract under section 1890(a), the Secretary
may specify a measure that is not so endorsed as long as due
consideration is given to measures that have been endorsed or
adopted by a consensus organization identified by the
Secretary.
(B) The reporting, collection, and validation of quality
data.
(C) The structure of value-based payment adjustments,
including the determination of thresholds or improvements in
quality that would substantiate a payment adjustment, the
size of such payments, and the sources of funding for the
value-based bonus payments.
(D) Methods for the public disclosure of information on the
performance of skilled nursing facilities.
(E) Any other issues determined appropriate by the
Secretary.
(3) Consultation.--In developing the plan under paragraph
(1), the Secretary shall--
(A) consult with relevant affected parties; and
(B) consider experience with such demonstrations that the
Secretary determines are relevant to the value-based
purchasing program described in paragraph (1).
(4) Report to congress.--Not later than October 1, 2011,
the Secretary shall submit to Congress a report containing
the plan developed under paragraph (1).
(b) Home Health Agencies.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
develop a plan to implement a value-based purchasing program
for payments under the Medicare program under title XVIII of
the Social Security Act for home health agencies (as defined
in section 1861(o) of such Act (42 U.S.C. 1395x(o))).
(2) Details.--In developing the plan under paragraph (1),
the Secretary shall consider the following issues:
(A) The ongoing development, selection, and modification
process for measures (including under section 1890 of the
Social Security Act (42 U.S.C. 1395aaa) and section 1890A
such Act, as added by section 3014), to the extent feasible
and practicable, of all dimensions of quality and efficiency
in home health agencies.
(B) The reporting, collection, and validation of quality
data.
(C) The structure of value-based payment adjustments,
including the determination of thresholds or improvements in
quality that would substantiate a payment adjustment, the
size of such payments, and the sources of funding for the
value-based bonus payments.
(D) Methods for the public disclosure of information on the
performance of home health agencies.
(E) Any other issues determined appropriate by the
Secretary.
(3) Consultation.--In developing the plan under paragraph
(1), the Secretary shall--
(A) consult with relevant affected parties; and
(B) consider experience with such demonstrations that the
Secretary determines are relevant to the value-based
purchasing program described in paragraph (1).
(4) Report to congress.--Not later than October 1, 2011,
the Secretary shall submit to Congress a report containing
the plan developed under paragraph (1).
SEC. 3007. VALUE-BASED PAYMENT MODIFIER UNDER THE PHYSICIAN
FEE SCHEDULE.
Section 1848 of the Social Security Act (42 U.S.C. 1395w-4)
is amended--
(1) in subsection (b)(1), by inserting ``subject to
subsection (p),'' after ``1998,''; and
(2) by adding at the end the following new subsection:
``(p) Establishment of Value-based Payment Modifier.--
[[Page H1987]]
``(1) In general.--The Secretary shall establish a payment
modifier that provides for differential payment to a
physician or a group of physicians under the fee schedule
established under subsection (b) based upon the quality of
care furnished compared to cost (as determined under
paragraphs (2) and (3), respectively) during a performance
period. Such payment modifier shall be separate from the
geographic adjustment factors established under subsection
(e).
``(2) Quality.--
``(A) In general.--For purposes of paragraph (1), quality
of care shall be evaluated, to the extent practicable, based
on a composite of measures of the quality of care furnished
(as established by the Secretary under subparagraph (B)).
``(B) Measures.--
``(i) The Secretary shall establish appropriate measures of
the quality of care furnished by a physician or group of
physicians to individuals enrolled under this part, such as
measures that reflect health outcomes. Such measures shall be
risk adjusted as determined appropriate by the Secretary.
``(ii) The Secretary shall seek endorsement of the measures
established under this subparagraph by the entity with a
contract under section 1890(a).
``(3) Costs.--For purposes of paragraph (1), costs shall be
evaluated, to the extent practicable, based on a composite of
appropriate measures of costs established by the Secretary
(such as the composite measure under the methodology
established under subsection (n)(9)(C)(iii)) that eliminate
the effect of geographic adjustments in payment rates (as
described in subsection (e)), and take into account risk
factors (such as socioeconomic and demographic
characteristics, ethnicity, and health status of individuals
(such as to recognize that less healthy individuals may
require more intensive interventions) and other factors
determined appropriate by the Secretary.
``(4) Implementation.--
``(A) Publication of measures, dates of implementation,
performance period.--Not later than January 1, 2012, the
Secretary shall publish the following:
``(i) The measures of quality of care and costs established
under paragraphs (2) and (3), respectively.
``(ii) The dates for implementation of the payment modifier
(as determined under subparagraph (B)).
``(iii) The initial performance period (as specified under
subparagraph (B)(ii)).
``(B) Deadlines for implementation.--
``(i) Initial implementation.--Subject to the preceding
provisions of this subparagraph, the Secretary shall begin
implementing the payment modifier established under this
subsection through the rulemaking process during 2013 for the
physician fee schedule established under subsection (b).
``(ii) Initial performance period.--
``(I) In general.--The Secretary shall specify an initial
performance period for application of the payment modifier
established under this subsection with respect to 2015.
``(II) Provision of information during initial performance
period.--During the initial performance period, the Secretary
shall, to the extent practicable, provide information to
physicians and groups of physicians about the quality of care
furnished by the physician or group of physicians to
individuals enrolled under this part compared to cost (as
determined under paragraphs (2) and (3), respectively) with
respect to the performance period.
``(iii) Application.--The Secretary shall apply the payment
modifier established under this subsection for items and
services furnished--
``(I) beginning on January 1, 2015, with respect to
specific physicians and groups of physicians the Secretary
determines appropriate; and
``(II) beginning not later than January 1, 2017, with
respect to all physicians and groups of physicians.
``(C) Budget neutrality.--The payment modifier established
under this subsection shall be implemented in a budget
neutral manner.
``(5) Systems-based care.--The Secretary shall, as
appropriate, apply the payment modifier established under
this subsection in a manner that promotes systems-based care.
``(6) Consideration of special circumstances of certain
providers.--In applying the payment modifier under this
subsection, the Secretary shall, as appropriate, take into
account the special circumstances of physicians or groups of
physicians in rural areas and other underserved communities.
``(7) Application.--For purposes of the initial application
of the payment modifier established under this subsection
during the period beginning on January 1, 2015, and ending on
December 31, 2016, the term `physician' has the meaning given
such term in section 1861(r). On or after January 1, 2017,
the Secretary may apply this subsection to eligible
professionals (as defined in subsection (k)(3)(B)) as the
Secretary determines appropriate.
``(8) Definitions.--For purposes of this subsection:
``(A) Costs.--The term `costs' means expenditures per
individual as determined appropriate by the Secretary. In
making the determination under the preceding sentence, the
Secretary may take into account the amount of growth in
expenditures per individual for a physician compared to the
amount of such growth for other physicians.
``(B) Performance period.--The term `performance period'
means a period specified by the Secretary.
``(9) Coordination with other value-based purchasing
reforms.--The Secretary shall coordinate the value-based
payment modifier established under this subsection with the
Physician Feedback Program under subsection (n) and, as the
Secretary determines appropriate, other similar provisions of
this title.
``(10) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of--
``(A) the establishment of the value-based payment modifier
under this subsection;
``(B) the evaluation of quality of care under paragraph
(2), including the establishment of appropriate measures of
the quality of care under paragraph (2)(B);
``(C) the evaluation of costs under paragraph (3),
including the establishment of appropriate measures of costs
under such paragraph;
``(D) the dates for implementation of the value-based
payment modifier;
``(E) the specification of the initial performance period
and any other performance period under paragraphs (4)(B)(ii)
and (8)(B), respectively;
``(F) the application of the value-based payment modifier
under paragraph (7); and
``(G) the determination of costs under paragraph (8)(A).''.
SEC. 3008. PAYMENT ADJUSTMENT FOR CONDITIONS ACQUIRED IN
HOSPITALS.
(a) In General.--Section 1886 of the Social Security Act
(42 U.S.C. 1395ww), as amended by section 3001, is amended by
adding at the end the following new subsection:
``(p) Adjustment to Hospital Payments for Hospital Acquired
Conditions.--
``(1) In general.--In order to provide an incentive for
applicable hospitals to reduce hospital acquired conditions
under this title, with respect to discharges from an
applicable hospital occurring during fiscal year 2015 or a
subsequent fiscal year, the amount of payment under this
section or section 1814(b)(3), as applicable, for such
discharges during the fiscal year shall be equal to 99
percent of the amount of payment that would otherwise apply
to such discharges under this section or section 1814(b)(3)
(determined after the application of subsections (o) and (q)
and section 1814(l)(4) but without regard to this
subsection).
``(2) Applicable hospitals.--
``(A) In general.--For purposes of this subsection, the
term `applicable hospital' means a subsection (d) hospital
that meets the criteria described in subparagraph (B).
``(B) Criteria described.--
``(i) In general.--The criteria described in this
subparagraph, with respect to a subsection (d) hospital, is
that the subsection (d) hospital is in the top quartile of
all subsection (d) hospitals, relative to the national
average, of hospital acquired conditions during the
applicable period, as determined by the Secretary.
``(ii) Risk adjustment.--In carrying out clause (i), the
Secretary shall establish and apply an appropriate risk
adjustment methodology.
``(C) Exemption.--In the case of a hospital that is paid
under section 1814(b)(3), the Secretary may exempt such
hospital from the application of this subsection if the State
which is paid under such section submits an annual report to
the Secretary describing how a similar program in the State
for a participating hospital or hospitals achieves or
surpasses the measured results in terms of patient health
outcomes and cost savings established under this subsection.
``(3) Hospital acquired conditions.--For purposes of this
subsection, the term `hospital acquired condition' means a
condition identified for purposes of subsection (d)(4)(D)(iv)
and any other condition determined appropriate by the
Secretary that an individual acquires during a stay in an
applicable hospital, as determined by the Secretary.
``(4) Applicable period.--In this subsection, the term
`applicable period' means, with respect to a fiscal year, a
period specified by the Secretary.
``(5) Reporting to hospitals.--Prior to fiscal year 2015
and each subsequent fiscal year, the Secretary shall provide
confidential reports to applicable hospitals with respect to
hospital acquired conditions of the applicable hospital
during the applicable period.
``(6) Reporting hospital specific information.--
``(A) In general.--The Secretary shall make information
available to the public regarding hospital acquired
conditions of each applicable hospital.
``(B) Opportunity to review and submit corrections.--The
Secretary shall ensure that an applicable hospital has the
opportunity to review, and submit corrections for, the
information to be made public with respect to the hospital
under subparagraph (A) prior to such information being made
public.
``(C) Website.--Such information shall be posted on the
Hospital Compare Internet website in an easily understandable
format.
``(7) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of the following:
``(A) The criteria described in paragraph (2)(A).
``(B) The specification of hospital acquired conditions
under paragraph (3).
``(C) The specification of the applicable period under
paragraph (4).
``(D) The provision of reports to applicable hospitals
under paragraph (5) and the information made available to the
public under paragraph (6).''.
(b) Study and Report on Expansion of Healthcare Acquired
Conditions Policy to Other Providers.--
(1) Study.--The Secretary of Health and Human Services
shall conduct a study on expanding the healthcare acquired
conditions policy under subsection (d)(4)(D) of section 1886
of the Social Security Act (42 U.S.C. 1395ww) to payments
made to other facilities under the Medicare program under
title XVIII of the Social Security Act, including such
payments
[[Page H1988]]
made to inpatient rehabilitation facilities, long-term care
hospitals (as described in subsection(d)(1)(B)(iv) of such
section), hospital outpatient departments, and other
hospitals excluded from the inpatient prospective payment
system under such section, skilled nursing facilities,
ambulatory surgical centers, and health clinics. Such study
shall include an analysis of how such policies could impact
quality of patient care, patient safety, and spending under
the Medicare program.
(2) Report.--Not later than January 1, 2012, the Secretary
shall submit to Congress a report containing the results of
the study conducted under paragraph (1), together with
recommendations for such legislation and administrative
action as the Secretary determines appropriate.
PART II--NATIONAL STRATEGY TO IMPROVE HEALTH CARE QUALITY
SEC. 3011. NATIONAL STRATEGY.
Title III of the Public Health Service Act (42 U.S.C. 241
et seq.) is amended by adding at the end the following:
``PART S--HEALTH CARE QUALITY PROGRAMS
``Subpart I--National Strategy for Quality Improvement in Health Care
``SEC. 399HH. NATIONAL STRATEGY FOR QUALITY IMPROVEMENT IN
HEALTH CARE.
``(a) Establishment of National Strategy and Priorities.--
``(1) National strategy.--The Secretary, through a
transparent collaborative process, shall establish a national
strategy to improve the delivery of health care services,
patient health outcomes, and population health.
``(2) Identification of priorities.--
``(A) In general.--The Secretary shall identify national
priorities for improvement in developing the strategy under
paragraph (1).
``(B) Requirements.--The Secretary shall ensure that
priorities identified under subparagraph (A) will--
``(i) have the greatest potential for improving the health
outcomes, efficiency, and patient-centeredness of health care
for all populations, including children and vulnerable
populations;
``(ii) identify areas in the delivery of health care
services that have the potential for rapid improvement in the
quality and efficiency of patient care;
``(iii) address gaps in quality, efficiency, comparative
effectiveness information, and health outcomes measures and
data aggregation techniques;
``(iv) improve Federal payment policy to emphasize quality
and efficiency;
``(v) enhance the use of health care data to improve
quality, efficiency, transparency, and outcomes;
``(vi) address the health care provided to patients with
high-cost chronic diseases;
``(vii) improve research and dissemination of strategies
and best practices to improve patient safety and reduce
medical errors, preventable admissions and readmissions, and
health care-associated infections;
``(viii) reduce health disparities across health disparity
populations (as defined in section 485E) and geographic
areas; and
``(ix) address other areas as determined appropriate by the
Secretary.
``(C) Considerations.--In identifying priorities under
subparagraph (A), the Secretary shall take into consideration
the recommendations submitted by the entity with a contract
under section 1890(a) of the Social Security Act and other
stakeholders.
``(D) Coordination with state agencies.--The Secretary
shall collaborate, coordinate, and consult with State
agencies responsible for administering the Medicaid program
under title XIX of the Social Security Act and the Children's
Health Insurance Program under title XXI of such Act with
respect to developing and disseminating strategies, goals,
models, and timetables that are consistent with the national
priorities identified under subparagraph (A).
``(b) Strategic Plan.--
``(1) In general.--The national strategy shall include a
comprehensive strategic plan to achieve the priorities
described in subsection (a).
``(2) Requirements.--The strategic plan shall include
provisions for addressing, at a minimum, the following:
``(A) Coordination among agencies within the Department,
which shall include steps to minimize duplication of efforts
and utilization of common quality measures, where available.
Such common quality measures shall be measures identified by
the Secretary under section 1139A or 1139B of the Social
Security Act or endorsed under section 1890 of such Act.
``(B) Agency-specific strategic plans to achieve national
priorities.
``(C) Establishment of annual benchmarks for each relevant
agency to achieve national priorities.
``(D) A process for regular reporting by the agencies to
the Secretary on the implementation of the strategic plan.
``(E) Strategies to align public and private payers with
regard to quality and patient safety efforts.
``(F) Incorporating quality improvement and measurement in
the strategic plan for health information technology required
by the American Recovery and Reinvestment Act of 2009 (Public
Law 111-5).
``(c) Periodic Update of National Strategy.--The Secretary
shall update the national strategy not less than annually.
Any such update shall include a review of short- and long-
term goals.
``(d) Submission and Availability of National Strategy and
Updates.--
``(1) Deadline for initial submission of national
strategy.--Not later than January 1, 2011, the Secretary
shall submit to the relevant committees of Congress the
national strategy described in subsection (a).
``(2) Updates.--
``(A) In general.--The Secretary shall submit to the
relevant committees of Congress an annual update to the
strategy described in paragraph (1).
``(B) Information submitted.--Each update submitted under
subparagraph (A) shall include--
``(i) a review of the short- and long-term goals of the
national strategy and any gaps in such strategy;
``(ii) an analysis of the progress, or lack of progress, in
meeting such goals and any barriers to such progress;
``(iii) the information reported under section 1139A of the
Social Security Act, consistent with the reporting
requirements of such section; and
``(iv) in the case of an update required to be submitted on
or after January 1, 2014, the information reported under
section 1139B(b)(4) of the Social Security Act, consistent
with the reporting requirements of such section.
``(C) Satisfaction of other reporting requirements.--
Compliance with the requirements of clauses (iii) and (iv) of
subparagraph (B) shall satisfy the reporting requirements
under sections 1139A(a)(6) and 1139B(b)(4), respectively, of
the Social Security Act.
``(e) Health Care Quality Internet Website.--Not later than
January 1, 2011, the Secretary shall create an Internet
website to make public information regarding--
``(1) the national priorities for health care quality
improvement established under subsection (a)(2);
``(2) the agency-specific strategic plans for health care
quality described in subsection (b)(2)(B); and
``(3) other information, as the Secretary determines to be
appropriate.''.
SEC. 3012. INTERAGENCY WORKING GROUP ON HEALTH CARE QUALITY.
(a) In General.--The President shall convene a working
group to be known as the Interagency Working Group on Health
Care Quality (referred to in this section as the ``Working
Group'').
(b) Goals.--The goals of the Working Group shall be to
achieve the following:
(1) Collaboration, cooperation, and consultation between
Federal departments and agencies with respect to developing
and disseminating strategies, goals, models, and timetables
that are consistent with the national priorities identified
under section 399HH(a)(2) of the Public Health Service Act
(as added by section 3011).
(2) Avoidance of inefficient duplication of quality
improvement efforts and resources, where practicable, and a
streamlined process for quality reporting and compliance
requirements.
(3) Assess alignment of quality efforts in the public
sector with private sector initiatives.
(c) Composition.--
(1) In general.--The Working Group shall be composed of
senior level representatives of--
(A) the Department of Health and Human Services;
(B) the Centers for Medicare & Medicaid Services;
(C) the National Institutes of Health;
(D) the Centers for Disease Control and Prevention;
(E) the Food and Drug Administration;
(F) the Health Resources and Services Administration;
(G) the Agency for Healthcare Research and Quality;
(H) the Office of the National Coordinator for Health
Information Technology;
(I) the Substance Abuse and Mental Health Services
Administration;
(J) the Administration for Children and Families;
(K) the Department of Commerce;
(L) the Office of Management and Budget;
(M) the United States Coast Guard;
(N) the Federal Bureau of Prisons;
(O) the National Highway Traffic Safety Administration;
(P) the Federal Trade Commission;
(Q) the Social Security Administration;
(R) the Department of Labor;
(S) the United States Office of Personnel Management;
(T) the Department of Defense;
(U) the Department of Education;
(V) the Department of Veterans Affairs;
(W) the Veterans Health Administration; and
(X) any other Federal agencies and departments with
activities relating to improving health care quality and
safety, as determined by the President.
(2) Chair and vice-chair.--
(A) Chair.--The Working Group shall be chaired by the
Secretary of Health and Human Services.
(B) Vice chair.--Members of the Working Group, other than
the Secretary of Health and Human Services, shall serve as
Vice Chair of the Group on a rotating basis, as determined by
the Group.
(d) Report to Congress.--Not later than December 31, 2010,
and annually thereafter, the Working Group shall submit to
the relevant Committees of Congress, and make public on an
Internet website, a report describing the progress and
recommendations of the Working Group in meeting the goals
described in subsection (b).
SEC. 3013. QUALITY MEASURE DEVELOPMENT.
(a) Public Health Service Act.--Title IX of the Public
Health Service Act (42 U.S.C. 299 et seq.) is amended--
(1) by redesignating part D as part E;
(2) by redesignating sections 931 through 938 as sections
941 through 948, respectively;
(3) in section 948(1), as so redesignated, by striking
``931'' and inserting ``941''; and
(4) by inserting after section 926 the following:
``PART D--HEALTH CARE QUALITY IMPROVEMENT
``Subpart I--Quality Measure Development
``SEC. 931. QUALITY MEASURE DEVELOPMENT.
``(a) Quality Measure.--In this subpart, the term `quality
measure' means a standard for
[[Page H1989]]
measuring the performance and improvement of population
health or of health plans, providers of services, and other
clinicians in the delivery of health care services.
``(b) Identification of Quality Measures.--
``(1) Identification.--The Secretary, in consultation with
the Director of the Agency for Healthcare Research and
Quality and the Administrator of the Centers for Medicare &
Medicaid Services, shall identify, not less often than
triennially, gaps where no quality measures exist and
existing quality measures that need improvement, updating, or
expansion, consistent with the national strategy under
section 399HH, to the extent available, for use in Federal
health programs. In identifying such gaps and existing
quality measures that need improvement, the Secretary shall
take into consideration--
``(A) the gaps identified by the entity with a contract
under section 1890(a) of the Social Security Act and other
stakeholders;
``(B) quality measures identified by the pediatric quality
measures program under section 1139A of the Social Security
Act; and
``(C) quality measures identified through the Medicaid
Quality Measurement Program under section 1139B of the Social
Security Act.
``(2) Publication.--The Secretary shall make available to
the public on an Internet website a report on any gaps
identified under paragraph (1) and the process used to make
such identification.
``(c) Grants or Contracts for Quality Measure
Development.--
``(1) In general.--The Secretary shall award grants,
contracts, or intergovernmental agreements to eligible
entities for purposes of developing, improving, updating, or
expanding quality measures identified under subsection (b).
``(2) Prioritization in the development of quality
measures.--In awarding grants, contracts, or agreements under
this subsection, the Secretary shall give priority to the
development of quality measures that allow the assessment
of--
``(A) health outcomes and functional status of patients;
``(B) the management and coordination of health care across
episodes of care and care transitions for patients across the
continuum of providers, health care settings, and health
plans;
``(C) the experience, quality, and use of information
provided to and used by patients, caregivers, and authorized
representatives to inform decisionmaking about treatment
options, including the use of shared decisionmaking tools and
preference sensitive care (as defined in section 936);
``(D) the meaningful use of health information technology;
``(E) the safety, effectiveness, patient-centeredness,
appropriateness, and timeliness of care;
``(F) the efficiency of care;
``(G) the equity of health services and health disparities
across health disparity populations (as defined in section
485E) and geographic areas;
``(H) patient experience and satisfaction;
``(I) the use of innovative strategies and methodologies
identified under section 933; and
``(J) other areas determined appropriate by the Secretary.
``(3) Eligible entities.--To be eligible for a grant or
contract under this subsection, an entity shall--
``(A) have demonstrated expertise and capacity in the
development and evaluation of quality measures;
``(B) have adopted procedures to include in the quality
measure development process--
``(i) the views of those providers or payers whose
performance will be assessed by the measure; and
``(ii) the views of other parties who also will use the
quality measures (such as patients, consumers, and health
care purchasers);
``(C) collaborate with the entity with a contract under
section 1890(a) of the Social Security Act and other
stakeholders, as practicable, and the Secretary so that
quality measures developed by the eligible entity will meet
the requirements to be considered for endorsement by the
entity with a contract under such section 1890(a);
``(D) have transparent policies regarding governance and
conflicts of interest; and
``(E) submit an application to the Secretary at such time
and in such manner, as the Secretary may require.
``(4) Use of funds.--An entity that receives a grant,
contract, or agreement under this subsection shall use such
award to develop quality measures that meet the following
requirements:
``(A) Such measures support measures required to be
reported under the Social Security Act, where applicable, and
in support of gaps and existing quality measures that need
improvement, as described in subsection (b)(1)(A).
``(B) Such measures support measures developed under
section 1139A of the Social Security Act and the Medicaid
Quality Measurement Program under section 1139B of such Act,
where applicable.
``(C) To the extent practicable, data on such quality
measures is able to be collected using health information
technologies.
``(D) Each quality measure is free of charge to users of
such measure.
``(E) Each quality measure is publicly available on an
Internet website.
``(d) Other Activities by the Secretary.--The Secretary may
use amounts available under this section to update and test,
where applicable, quality measures endorsed by the entity
with a contract under section 1890(a) of the Social Security
Act or adopted by the Secretary.
``(e) Coordination of Grants.--The Secretary shall ensure
that grants or contracts awarded under this section are
coordinated with grants and contracts awarded under sections
1139A(5) and 1139B(4)(A) of the Social Security Act.''.
(b) Social Security Act.--Section 1890A of the Social
Security Act, as added by section 3014(b), is amended by
adding at the end the following new subsection:
``(e) Development of Quality Measures.--The Administrator
of the Center for Medicare & Medicaid Services shall through
contracts develop quality measures (as determined appropriate
by the Administrator) for use under this Act. In developing
such measures, the Administrator shall consult with the
Director of the Agency for Healthcare Research and
Quality.''.
(c) Funding.--There are authorized to be appropriated to
the Secretary of Health and Human Services to carry out this
section, $75,000,000 for each of fiscal years 2010 through
2014. Of the amounts appropriated under the preceding
sentence in a fiscal year, not less than 50 percent of such
amounts shall be used pursuant to subsection (e) of section
1890A of the Social Security Act, as added by subsection (b),
with respect to programs under such Act. Amounts appropriated
under this subsection for a fiscal year shall remain
available until expended.
SEC. 3014. QUALITY MEASUREMENT.
(a) New Duties for Consensus-based Entity.--
(1) Multi-stakeholder group input.--Section 1890(b) of the
Social Security Act (42 U.S.C. 1395aaa(b)), as amended by
section 3003, is amended by adding at the end the following
new paragraphs:
``(7) Convening multi-stakeholder groups.--
``(A) In general.--The entity shall convene multi-
stakeholder groups to provide input on--
``(i) the selection of quality measures described in
subparagraph (B), from among--
``(I) such measures that have been endorsed by the entity;
and
``(II) such measures that have not been considered for
endorsement by such entity but are used or proposed to be
used by the Secretary for the collection or reporting of
quality measures; and
``(ii) national priorities (as identified under section
399HH of the Public Health Service Act) for improvement in
population health and in the delivery of health care services
for consideration under the national strategy established
under section 399HH of the Public Health Service Act.
``(B) Quality measures.--
``(i) In general.--Subject to clause (ii), the quality
measures described in this subparagraph are quality
measures--
``(I) for use pursuant to sections 1814(i)(5)(D),
1833(i)(7), 1833(t)(17), 1848(k)(2)(C), 1866(k)(3),
1881(h)(2)(A)(iii), 1886(b)(3)(B)(viii), 1886(j)(7)(D),
1886(m)(5)(D), 1886(o)(2), and 1895(b)(3)(B)(v);
``(II) for use in reporting performance information to the
public; and
``(III) for use in health care programs other than for use
under this Act.
``(ii) Exclusion.--Data sets (such as the outcome and
assessment information set for home health services and the
minimum data set for skilled nursing facility services) that
are used for purposes of classification systems used in
establishing payment rates under this title shall not be
quality measures described in this subparagraph.
``(C) Requirement for transparency in process.--
``(i) In general.--In convening multi-stakeholder groups
under subparagraph (A) with respect to the selection of
quality measures, the entity shall provide for an open and
transparent process for the activities conducted pursuant to
such convening.
``(ii) Selection of organizations participating in multi-
stakeholder groups.--The process described in clause (i)
shall ensure that the selection of representatives comprising
such groups provides for public nominations for, and the
opportunity for public comment on, such selection.
``(D) Multi-stakeholder group defined.--In this paragraph,
the term `multi-stakeholder group' means, with respect to a
quality measure, a voluntary collaborative of organizations
representing a broad group of stakeholders interested in or
affected by the use of such quality measure.
``(8) Transmission of multi-stakeholder input.--Not later
than February 1 of each year (beginning with 2012), the
entity shall transmit to the Secretary the input of multi-
stakeholder groups provided under paragraph (7).''.
(2) Annual report.--Section 1890(b)(5)(A) of the Social
Security Act (42 U.S.C. 1395aaa(b)(5)(A)) is amended--
(A) in clause (ii), by striking ``and'' at the end;
(B) in clause (iii), by striking the period at the end and
inserting a semicolon; and
(C) by adding at the end the following new clauses:
``(iv) gaps in endorsed quality measures, which shall
include measures that are within priority areas identified by
the Secretary under the national strategy established under
section 399HH of the Public Health Service Act, and where
quality measures are unavailable or inadequate to identify or
address such gaps;
``(v) areas in which evidence is insufficient to support
endorsement of quality measures in priority areas identified
by the Secretary under the national strategy established
under section 399HH of the Public Health Service Act and
where targeted research may address such gaps; and
``(vi) the matters described in clauses (i) and (ii) of
paragraph (7)(A).''.
(b) Multi-stakeholder Group Input Into Selection of Quality
Measures.--Title XVIII of the Social Security Act (42 U.S.C.
1395 et seq.) is amended by inserting after section 1890 the
following:
[[Page H1990]]
``quality measurement
``Sec. 1890A. (a) Multi-stakeholder Group Input Into
Selection of Quality Measures.--The Secretary shall establish
a pre-rulemaking process under which the following steps
occur with respect to the selection of quality measures
described in section 1890(b)(7)(B):
``(1) Input.--Pursuant to section 1890(b)(7), the entity
with a contract under section 1890 shall convene multi-
stakeholder groups to provide input to the Secretary on the
selection of quality measures described in subparagraph (B)
of such paragraph.
``(2) Public availability of measures considered for
selection.--Not later than December 1 of each year (beginning
with 2011), the Secretary shall make available to the public
a list of quality measures described in section 1890(b)(7)(B)
that the Secretary is considering under this title.
``(3) Transmission of multi-stakeholder input.--Pursuant to
section 1890(b)(8), not later than February 1 of each year
(beginning with 2012), the entity shall transmit to the
Secretary the input of multi-stakeholder groups described in
paragraph (1).
``(4) Consideration of multi-stakeholder input.--The
Secretary shall take into consideration the input from multi-
stakeholder groups described in paragraph (1) in selecting
quality measures described in section 1890(b)(7)(B) that have
been endorsed by the entity with a contract under section
1890 and measures that have not been endorsed by such entity.
``(5) Rationale for use of quality measures.--The Secretary
shall publish in the Federal Register the rationale for the
use of any quality measure described in section 1890(b)(7)(B)
that has not been endorsed by the entity with a contract
under section 1890.
``(6) Assessment of impact.--Not later than March 1, 2012,
and at least once every three years thereafter, the Secretary
shall--
``(A) conduct an assessment of the quality impact of the
use of endorsed measures described in section 1890(b)(7)(B);
and
``(B) make such assessment available to the public.
``(b) Process for Dissemination of Measures Used by the
Secretary.--
``(1) In general.--The Secretary shall establish a process
for disseminating quality measures used by the Secretary.
Such process shall include the following:
``(A) The incorporation of such measures, where applicable,
in workforce programs, training curricula, and any other
means of dissemination determined appropriate by the
Secretary.
``(B) The dissemination of such quality measures through
the national strategy developed under section 399HH of the
Public Health Service Act.
``(2) Existing methods.--To the extent practicable, the
Secretary shall utilize and expand existing dissemination
methods in disseminating quality measures under the process
established under paragraph (1).
``(c) Review of Quality Measures Used by the Secretary.--
``(1) In general.--The Secretary shall--
``(A) periodically (but in no case less often than once
every 3 years) review quality measures described in section
1890(b)(7)(B); and
``(B) with respect to each such measure, determine whether
to--
``(i) maintain the use of such measure; or
``(ii) phase out such measure.
``(2) Considerations.--In conducting the review under
paragraph (1), the Secretary shall take steps to--
``(A) seek to avoid duplication of measures used; and
``(B) take into consideration current innovative
methodologies and strategies for quality improvement
practices in the delivery of health care services that
represent best practices for such quality improvement and
measures endorsed by the entity with a contract under section
1890 since the previous review by the Secretary.
``(d) Rule of Construction.--Nothing in this section shall
preclude a State from using the quality measures identified
under sections 1139A and 1139B.''.
(c) Funding.--For purposes of carrying out the amendments
made by this section, the Secretary shall provide for the
transfer, from the Federal Hospital Insurance Trust Fund
under section 1817 of the Social Security Act (42 U.S.C.
1395i) and the Federal Supplementary Medical Insurance Trust
Fund under section 1841 of such Act (42 U.S.C. 1395t), in
such proportion as the Secretary determines appropriate, of
$20,000,000, to the Centers for Medicare & Medicaid Services
Program Management Account for each of fiscal years 2010
through 2014. Amounts transferred under the preceding
sentence shall remain available until expended.
SEC. 3015. DATA COLLECTION; PUBLIC REPORTING.
Title III of the Public Health Service Act (42 U.S.C. 241
et seq.), as amended by section 3011, is further amended by
adding at the end the following:
``SEC. 399II. COLLECTION AND ANALYSIS OF DATA FOR QUALITY AND
RESOURCE USE MEASURES.
``(a) In General.--The Secretary shall collect and
aggregate consistent data on quality and resource use
measures from information systems used to support health care
delivery to implement the public reporting of performance
information, as described in section 399JJ, and may award
grants or contracts for this purpose. The Secretary shall
ensure that such collection, aggregation, and analysis
systems span an increasingly broad range of patient
populations, providers, and geographic areas over time.
``(b) Grants or Contracts for Data Collection.--
``(1) In general.--The Secretary may award grants or
contracts to eligible entities to support new, or improve
existing, efforts to collect and aggregate quality and
resource use measures described under subsection (c).
``(2) Eligible entities.--To be eligible for a grant or
contract under this subsection, an entity shall--
``(A) be--
``(i) a multi-stakeholder entity that coordinates the
development of methods and implementation plans for the
consistent reporting of summary quality and cost information;
``(ii) an entity capable of submitting such summary data
for a particular population and providers, such as a disease
registry, regional collaboration, health plan collaboration,
or other population-wide source; or
``(iii) a Federal Indian Health Service program or a health
program operated by an Indian tribe (as defined in section 4
of the Indian Health Care Improvement Act);
``(B) promote the use of the systems that provide data to
improve and coordinate patient care;
``(C) support the provision of timely, consistent quality
and resource use information to health care providers, and
other groups and organizations as appropriate, with an
opportunity for providers to correct inaccurate measures; and
``(D) agree to report, as determined by the Secretary,
measures on quality and resource use to the public in
accordance with the public reporting process established
under section 399JJ.
``(c) Consistent Data Aggregation.--The Secretary may award
grants or contracts under this section only to entities that
enable summary data that can be integrated and compared
across multiple sources. The Secretary shall provide
standards for the protection of the security and privacy of
patient data.
``(d) Matching Funds.--The Secretary may not award a grant
or contract under this section to an entity unless the entity
agrees that it will make available (directly or through
contributions from other public or private entities) non-
Federal contributions toward the activities to be carried out
under the grant or contract in an amount equal to $1 for each
$5 of Federal funds provided under the grant or contract.
Such non-Federal matching funds may be provided directly or
through donations from public or private entities and may be
in cash or in-kind, fairly evaluated, including plant,
equipment, or services.
``(e) Authorization of Appropriations.--To carry out this
section, there are authorized to be appropriated such sums as
may be necessary for fiscal years 2010 through 2014.
``SEC. 399JJ. PUBLIC REPORTING OF PERFORMANCE INFORMATION.
``(a) Development of Performance Websites.--The Secretary
shall make available to the public, through standardized
Internet websites, performance information summarizing data
on quality measures. Such information shall be tailored to
respond to the differing needs of hospitals and other
institutional health care providers, physicians and other
clinicians, patients, consumers, researchers, policymakers,
States, and other stakeholders, as the Secretary may specify.
``(b) Information on Conditions.--The performance
information made publicly available on an Internet website,
as described in subsection (a), shall include information
regarding clinical conditions to the extent such information
is available, and the information shall, where appropriate,
be provider-specific and sufficiently disaggregated and
specific to meet the needs of patients with different
clinical conditions.
``(c) Consultation.--
``(1) In general.--In carrying out this section, the
Secretary shall consult with the entity with a contract under
section 1890(a) of the Social Security Act, and other
entities, as appropriate, to determine the type of
information that is useful to stakeholders and the format
that best facilitates use of the reports and of performance
reporting Internet websites.
``(2) Consultation with stakeholders.--The entity with a
contract under section 1890(a) of the Social Security Act
shall convene multi-stakeholder groups, as described in such
section, to review the design and format of each Internet
website made available under subsection (a) and shall
transmit to the Secretary the views of such multi-stakeholder
groups with respect to each such design and format.
``(d) Coordination.--Where appropriate, the Secretary shall
coordinate the manner in which data are presented through
Internet websites described in subsection (a) and for public
reporting of other quality measures by the Secretary,
including such quality measures under title XVIII of the
Social Security Act.
``(e) Authorization of Appropriations.--To carry out this
section, there are authorized to be appropriated such sums as
may be necessary for fiscal years 2010 through 2014.''.
PART III--ENCOURAGING DEVELOPMENT OF NEW PATIENT CARE MODELS
SEC. 3021. ESTABLISHMENT OF CENTER FOR MEDICARE AND MEDICAID
INNOVATION WITHIN CMS.
(a) In General.--Title XI of the Social Security Act is
amended by inserting after section 1115 the following new
section:
``center for medicare and medicaid innovation
``Sec. 1115A. (a) Center for Medicare and Medicaid
Innovation Established.--
``(1) In general.--There is created within the Centers for
Medicare & Medicaid Services a Center for Medicare and
Medicaid Innovation (in this section referred to as the
`CMI') to carry out the duties described in this section. The
purpose of the CMI is to test innovative payment and service
delivery models to reduce program expenditures under the
applicable titles while
[[Page H1991]]
preserving or enhancing the quality of care furnished to
individuals under such titles. In selecting such models, the
Secretary shall give preference to models that also improve
the coordination, quality, and efficiency of health care
services furnished to applicable individuals defined in
paragraph (4)(A).
``(2) Deadline.--The Secretary shall ensure that the CMI is
carrying out the duties described in this section by not
later than January 1, 2011.
``(3) Consultation.--In carrying out the duties under this
section, the CMI shall consult representatives of relevant
Federal agencies, and clinical and analytical experts with
expertise in medicine and health care management. The CMI
shall use open door forums or other mechanisms to seek input
from interested parties.
``(4) Definitions.--In this section:
``(A) Applicable individual.--The term `applicable
individual' means--
``(i) an individual who is entitled to, or enrolled for,
benefits under part A of title XVIII or enrolled for benefits
under part B of such title;
``(ii) an individual who is eligible for medical assistance
under title XIX, under a State plan or waiver; or
``(iii) an individual who meets the criteria of both
clauses (i) and (ii).
``(B) Applicable title.--The term `applicable title' means
title XVIII, title XIX, or both.
``(b) Testing of Models (Phase I).--
``(1) In general.--The CMI shall test payment and service
delivery models in accordance with selection criteria under
paragraph (2) to determine the effect of applying such models
under the applicable title (as defined in subsection
(a)(4)(B)) on program expenditures under such titles and the
quality of care received by individuals receiving benefits
under such title.
``(2) Selection of models to be tested.--
``(A) In general.--The Secretary shall select models to be
tested from models where the Secretary determines that there
is evidence that the model addresses a defined population for
which there are deficits in care leading to poor clinical
outcomes or potentially avoidable expenditures. The models
selected under the preceding sentence may include the models
described in subparagraph (B).
``(B) Opportunities.--The models described in this
subparagraph are the following models:
``(i) Promoting broad payment and practice reform in
primary care, including patient-centered medical home models
for high-need applicable individuals, medical homes that
address women's unique health care needs, and models that
transition primary care practices away from fee-for-service
based reimbursement and toward comprehensive payment or
salary-based payment.
``(ii) Contracting directly with groups of providers of
services and suppliers to promote innovative care delivery
models, such as through risk-based comprehensive payment or
salary-based payment.
``(iii) Utilizing geriatric assessments and comprehensive
care plans to coordinate the care (including through
interdisciplinary teams) of applicable individuals with
multiple chronic conditions and at least one of the
following:
``(I) An inability to perform 2 or more activities of daily
living.
``(II) Cognitive impairment, including dementia.
``(iv) Promote care coordination between providers of
services and suppliers that transition health care providers
away from fee-for-service based reimbursement and toward
salary-based payment.
``(v) Supporting care coordination for chronically-ill
applicable individuals at high risk of hospitalization
through a health information technology-enabled provider
network that includes care coordinators, a chronic disease
registry, and home tele-health technology.
``(vi) Varying payment to physicians who order advanced
diagnostic imaging services (as defined in section
1834(e)(1)(B)) according to the physician's adherence to
appropriateness criteria for the ordering of such services,
as determined in consultation with physician specialty groups
and other relevant stakeholders.
``(vii) Utilizing medication therapy management services,
such as those described in section 935 of the Public Health
Service Act.
``(viii) Establishing community-based health teams to
support small-practice medical homes by assisting the primary
care practitioner in chronic care management, including
patient self-management, activities.
``(ix) Assisting applicable individuals in making informed
health care choices by paying providers of services and
suppliers for using patient decision-support tools, including
tools that meet the standards developed and identified under
section 936(c)(2)(A) of the Public Health Service Act, that
improve applicable individual and caregiver understanding of
medical treatment options.
``(x) Allowing States to test and evaluate fully
integrating care for dual eligible individuals in the State,
including the management and oversight of all funds under the
applicable titles with respect to such individuals.
``(xi) Allowing States to test and evaluate systems of all-
payer payment reform for the medical care of residents of the
State, including dual eligible individuals.
``(xii) Aligning nationally recognized, evidence-based
guidelines of cancer care with payment incentives under title
XVIII in the areas of treatment planning and follow-up care
planning for applicable individuals described in clause (i)
or (iii) of subsection (a)(4)(A) with cancer, including the
identification of gaps in applicable quality measures.
``(xiii) Improving post-acute care through continuing care
hospitals that offer inpatient rehabilitation, long-term care
hospitals, and home health or skilled nursing care during an
inpatient stay and the 30 days immediately following
discharge.
``(xiv) Funding home health providers who offer chronic
care management services to applicable individuals in
cooperation with interdisciplinary teams.
``(xv) Promoting improved quality and reduced cost by
developing a collaborative of high-quality, low-cost health
care institutions that is responsible for--
``(I) developing, documenting, and disseminating best
practices and proven care methods;
``(II) implementing such best practices and proven care
methods within such institutions to demonstrate further
improvements in quality and efficiency; and
``(III) providing assistance to other health care
institutions on how best to employ such best practices and
proven care methods to improve health care quality and lower
costs.
``(xvi) Facilitate inpatient care, including intensive
care, of hospitalized applicable individuals at their local
hospital through the use of electronic monitoring by
specialists, including intensivists and critical care
specialists, based at integrated health systems.
``(xvii) Promoting greater efficiencies and timely access
to outpatient services (such as outpatient physical therapy
services) through models that do not require a physician or
other health professional to refer the service or be involved
in establishing the plan of care for the service, when such
service is furnished by a health professional who has the
authority to furnish the service under existing State law.
``(xviii) Establishing comprehensive payments to Healthcare
Innovation Zones, consisting of groups of providers that
include a teaching hospital, physicians, and other clinical
entities, that, through their structure, operations, and
joint-activity deliver a full spectrum of integrated and
comprehensive health care services to applicable individuals
while also incorporating innovative methods for the clinical
training of future health care professionals.
``(C) Additional factors for consideration.--In selecting
models for testing under subparagraph (A), the CMI may
consider the following additional factors:
``(i) Whether the model includes a regular process for
monitoring and updating patient care plans in a manner that
is consistent with the needs and preferences of applicable
individuals.
``(ii) Whether the model places the applicable individual,
including family members and other informal caregivers of the
applicable individual, at the center of the care team of the
applicable individual.
``(iii) Whether the model provides for in-person contact
with applicable individuals.
``(iv) Whether the model utilizes technology, such as
electronic health records and patient-based remote monitoring
systems, to coordinate care over time and across settings.
``(v) Whether the model provides for the maintenance of a
close relationship between care coordinators, primary care
practitioners, specialist physicians, community-based
organizations, and other providers of services and suppliers.
``(vi) Whether the model relies on a team-based approach to
interventions, such as comprehensive care assessments, care
planning, and self-management coaching.
``(vii) Whether, under the model, providers of services and
suppliers are able to share information with patients,
caregivers, and other providers of services and suppliers on
a real time basis.
``(3) Budget neutrality.--
``(A) Initial period.--The Secretary shall not require, as
a condition for testing a model under paragraph (1), that the
design of such model ensure that such model is budget neutral
initially with respect to expenditures under the applicable
title.
``(B) Termination or modification.--The Secretary shall
terminate or modify the design and implementation of a model
unless the Secretary determines (and the Chief Actuary of the
Centers for Medicare & Medicaid Services, with respect to
program spending under the applicable title, certifies),
after testing has begun, that the model is expected to--
``(i) improve the quality of care (as determined by the
Administrator of the Centers for Medicare & Medicaid
Services) without increasing spending under the applicable
title;
``(ii) reduce spending under the applicable title without
reducing the quality of care; or
``(iii) improve the quality of care and reduce spending.
Such termination may occur at any time after such testing has
begun and before completion of the testing.
``(4) Evaluation.--
``(A) In general.--The Secretary shall conduct an
evaluation of each model tested under this subsection. Such
evaluation shall include an analysis of--
``(i) the quality of care furnished under the model,
including the measurement of patient-level outcomes and
patient-centeredness criteria determined appropriate by the
Secretary; and
``(ii) the changes in spending under the applicable titles
by reason of the model.
``(B) Information.--The Secretary shall make the results of
each evaluation under this paragraph available to the public
in a timely fashion and may establish requirements for States
and other entities participating in the testing of models
under this section to collect and report information that the
Secretary determines is necessary to monitor and evaluate
such models.
``(c) Expansion of Models (Phase II).--Taking into account
the evaluation under subsection (b)(4), the Secretary may,
through rulemaking, expand (including implementation on a
nationwide basis) the duration and the scope of a model that
is being tested under subsection (b)
[[Page H1992]]
or a demonstration project under section 1866C, to the extent
determined appropriate by the Secretary, if--
``(1) the Secretary determines that such expansion is
expected to--
``(A) reduce spending under applicable title without
reducing the quality of care; or
``(B) improve the quality of care and reduce spending; and
``(2) the Chief Actuary of the Centers for Medicare &
Medicaid Services certifies that such expansion would reduce
program spending under applicable titles.
``(d) Implementation.--
``(1) Waiver authority.--The Secretary may waive such
requirements of titles XI and XVIII and of sections
1902(a)(1), 1902(a)(13), and 1903(m)(2)(A)(iii) as may be
necessary solely for purposes of carrying out this section
with respect to testing models described in subsection (b).
``(2) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of--
``(A) the selection of models for testing or expansion
under this section;
``(B) the selection of organizations, sites, or
participants to test those models selected;
``(C) the elements, parameters, scope, and duration of such
models for testing or dissemination;
``(D) determinations regarding budget neutrality under
subsection (b)(3);
``(E) the termination or modification of the design and
implementation of a model under subsection (b)(3)(B); and
``(F) determinations about expansion of the duration and
scope of a model under subsection (c), including the
determination that a model is not expected to meet criteria
described in paragraph (1) or (2) of such subsection.
``(3) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to the testing and evaluation of
models or expansion of such models under this section.
``(e) Application to CHIP.--The Center may carry out
activities under this section with respect to title XXI in
the same manner as provided under this section with respect
to the program under the applicable titles.
``(f) Funding.--
``(1) In general.--There are appropriated, from amounts in
the Treasury not otherwise appropriated--
``(A) $5,000,000 for the design, implementation, and
evaluation of models under subsection (b) for fiscal year
2010;
``(B) $10,000,000,000 for the activities initiated under
this section for the period of fiscal years 2011 through
2019; and
``(C) the amount described in subparagraph (B) for the
activities initiated under this section for each subsequent
10-year fiscal period (beginning with the 10-year fiscal
period beginning with fiscal year 2020).
Amounts appropriated under the preceding sentence shall
remain available until expended.
``(2) Use of certain funds.--Out of amounts appropriated
under subparagraphs (B) and (C) of paragraph (1), not less
than $25,000,000 shall be made available each such fiscal
year to design, implement, and evaluate models under
subsection (b).
``(g) Report to Congress.--Beginning in 2012, and not less
than once every other year thereafter, the Secretary shall
submit to Congress a report on activities under this section.
Each such report shall describe the models tested under
subsection (b), including the number of individuals described
in subsection (a)(4)(A)(i) and of individuals described in
subsection (a)(4)(A)(ii) participating in such models and
payments made under applicable titles for services on behalf
of such individuals, any models chosen for expansion under
subsection (c), and the results from evaluations under
subsection (b)(4). In addition, each such report shall
provide such recommendations as the Secretary determines are
appropriate for legislative action to facilitate the
development and expansion of successful payment models.''.
(b) Medicaid Conforming Amendment.--Section 1902(a) of the
Social Security Act (42 U.S.C. 1396a(a)), as amended by
section 8002(b), is amended--
(1) in paragraph (81), by striking ``and'' at the end;
(2) in paragraph (82), by striking the period at the end
and inserting ``; and''; and
(3) by inserting after paragraph (82) the following new
paragraph:
``(83) provide for implementation of the payment models
specified by the Secretary under section 1115A(c) for
implementation on a nationwide basis unless the State
demonstrates to the satisfaction of the Secretary that
implementation would not be administratively feasible or
appropriate to the health care delivery system of the
State.''.
(c) Revisions to Health Care Quality Demonstration
Program.--Subsections (b) and (f) of section 1866C of the
Social Security Act (42 U.S.C. 1395cc-3) are amended by
striking ``5-year'' each place it appears.
SEC. 3022. MEDICARE SHARED SAVINGS PROGRAM.
Title XVIII of the Social Security Act (42 U.S.C. 1395 et
seq.) is amended by adding at the end the following new
section:
``shared savings program
``Sec. 1899. (a) Establishment.--
``(1) In general.--Not later than January 1, 2012, the
Secretary shall establish a shared savings program (in this
section referred to as the `program') that promotes
accountability for a patient population and coordinates items
and services under parts A and B, and encourages investment
in infrastructure and redesigned care processes for high
quality and efficient service delivery. Under such program--
``(A) groups of providers of services and suppliers meeting
criteria specified by the Secretary may work together to
manage and coordinate care for Medicare fee-for-service
beneficiaries through an accountable care organization
(referred to in this section as an `ACO'); and
``(B) ACOs that meet quality performance standards
established by the Secretary are eligible to receive payments
for shared savings under subsection (d)(2).
``(b) Eligible ACOs.--
``(1) In general.--Subject to the succeeding provisions of
this subsection, as determined appropriate by the Secretary,
the following groups of providers of services and suppliers
which have established a mechanism for shared governance are
eligible to participate as ACOs under the program under this
section:
``(A) ACO professionals in group practice arrangements.
``(B) Networks of individual practices of ACO
professionals.
``(C) Partnerships or joint venture arrangements between
hospitals and ACO professionals.
``(D) Hospitals employing ACO professionals.
``(E) Such other groups of providers of services and
suppliers as the Secretary determines appropriate.
``(2) Requirements.--An ACO shall meet the following
requirements:
``(A) The ACO shall be willing to become accountable for
the quality, cost, and overall care of the Medicare fee-for-
service beneficiaries assigned to it.
``(B) The ACO shall enter into an agreement with the
Secretary to participate in the program for not less than a
3-year period (referred to in this section as the `agreement
period').
``(C) The ACO shall have a formal legal structure that
would allow the organization to receive and distribute
payments for shared savings under subsection (d)(2) to
participating providers of services and suppliers.
``(D) The ACO shall include primary care ACO professionals
that are sufficient for the number of Medicare fee-for-
service beneficiaries assigned to the ACO under subsection
(c). At a minimum, the ACO shall have at least 5,000 such
beneficiaries assigned to it under subsection (c) in order to
be eligible to participate in the ACO program.
``(E) The ACO shall provide the Secretary with such
information regarding ACO professionals participating in the
ACO as the Secretary determines necessary to support the
assignment of Medicare fee-for-service beneficiaries to an
ACO, the implementation of quality and other reporting
requirements under paragraph (3), and the determination of
payments for shared savings under subsection (d)(2).
``(F) The ACO shall have in place a leadership and
management structure that includes clinical and
administrative systems.
``(G) The ACO shall define processes to promote evidence-
based medicine and patient engagement, report on quality and
cost measures, and coordinate care, such as through the use
of telehealth, remote patient monitoring, and other such
enabling technologies.
``(H) The ACO shall demonstrate to the Secretary that it
meets patient-centeredness criteria specified by the
Secretary, such as the use of patient and caregiver
assessments or the use of individualized care plans.
``(3) Quality and other reporting requirements.--
``(A) In general.--The Secretary shall determine
appropriate measures to assess the quality of care furnished
by the ACO, such as measures of--
``(i) clinical processes and outcomes;
``(ii) patient and, where practicable, caregiver experience
of care; and
``(iii) utilization (such as rates of hospital admissions
for ambulatory care sensitive conditions).
``(B) Reporting requirements.--An ACO shall submit data in
a form and manner specified by the Secretary on measures the
Secretary determines necessary for the ACO to report in order
to evaluate the quality of care furnished by the ACO. Such
data may include care transitions across health care
settings, including hospital discharge planning and post-
hospital discharge follow-up by ACO professionals, as the
Secretary determines appropriate.
``(C) Quality performance standards.--The Secretary shall
establish quality performance standards to assess the quality
of care furnished by ACOs. The Secretary shall seek to
improve the quality of care furnished by ACOs over time by
specifying higher standards, new measures, or both for
purposes of assessing such quality of care.
``(D) Other reporting requirements.--The Secretary may, as
the Secretary determines appropriate, incorporate reporting
requirements and incentive payments related to the physician
quality reporting initiative (PQRI) under section 1848,
including such requirements and such payments related to
electronic prescribing, electronic health records, and other
similar initiatives under section 1848, and may use
alternative criteria than would otherwise apply under such
section for determining whether to make such payments. The
incentive payments described in the preceding sentence shall
not be taken into consideration when calculating any payments
otherwise made under subsection (d).
``(4) No duplication in participation in shared savings
programs.--A provider of services or supplier that
participates in any of the following shall not be eligible to
participate in an ACO under this section:
``(A) A model tested or expanded under section 1115A that
involves shared savings under this title, or any other
program or demonstration project that involves such shared
savings.
``(B) The independence at home medical practice pilot
program under section 1866E.
``(c) Assignment of Medicare Fee-for-service Beneficiaries
to ACOs.--The Secretary
[[Page H1993]]
shall determine an appropriate method to assign Medicare fee-
for-service beneficiaries to an ACO based on their
utilization of primary care services provided under this
title by an ACO professional described in subsection
(h)(1)(A).
``(d) Payments and Treatment of Savings.--
``(1) Payments.--
``(A) In general.--Under the program, subject to paragraph
(3), payments shall continue to be made to providers of
services and suppliers participating in an ACO under the
original Medicare fee-for-service program under parts A and B
in the same manner as they would otherwise be made except
that a participating ACO is eligible to receive payment for
shared savings under paragraph (2) if--
``(i) the ACO meets quality performance standards
established by the Secretary under subsection (b)(3); and
``(ii) the ACO meets the requirement under subparagraph
(B)(i).
``(B) Savings requirement and benchmark.--
``(i) Determining savings.--In each year of the agreement
period, an ACO shall be eligible to receive payment for
shared savings under paragraph (2) only if the estimated
average per capita Medicare expenditures under the ACO for
Medicare fee-for-service beneficiaries for parts A and B
services, adjusted for beneficiary characteristics, is at
least the percent specified by the Secretary below the
applicable benchmark under clause (ii). The Secretary shall
determine the appropriate percent described in the preceding
sentence to account for normal variation in expenditures
under this title, based upon the number of Medicare fee-for-
service beneficiaries assigned to an ACO.
``(ii) Establish and update benchmark.--The Secretary shall
estimate a benchmark for each agreement period for each ACO
using the most recent available 3 years of per-beneficiary
expenditures for parts A and B services for Medicare fee-for-
service beneficiaries assigned to the ACO. Such benchmark
shall be adjusted for beneficiary characteristics and such
other factors as the Secretary determines appropriate and
updated by the projected absolute amount of growth in
national per capita expenditures for parts A and B services
under the original Medicare fee-for-service program, as
estimated by the Secretary. Such benchmark shall be reset at
the start of each agreement period.
``(2) Payments for shared savings.--Subject to performance
with respect to the quality performance standards established
by the Secretary under subsection (b)(3), if an ACO meets the
requirements under paragraph (1), a percent (as determined
appropriate by the Secretary) of the difference between such
estimated average per capita Medicare expenditures in a year,
adjusted for beneficiary characteristics, under the ACO and
such benchmark for the ACO may be paid to the ACO as shared
savings and the remainder of such difference shall be
retained by the program under this title. The Secretary shall
establish limits on the total amount of shared savings that
may be paid to an ACO under this paragraph.
``(3) Monitoring avoidance of at-risk patients.--If the
Secretary determines that an ACO has taken steps to avoid
patients at risk in order to reduce the likelihood of
increasing costs to the ACO the Secretary may impose an
appropriate sanction on the ACO, including termination from
the program.
``(4) Termination.--The Secretary may terminate an
agreement with an ACO if it does not meet the quality
performance standards established by the Secretary under
subsection (b)(3).
``(e) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to the program.
``(f) Waiver Authority.--The Secretary may waive such
requirements of sections 1128A and 1128B and title XVIII of
this Act as may be necessary to carry out the provisions of
this section.
``(g) Limitations on Review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of--
``(1) the specification of criteria under subsection
(a)(1)(B);
``(2) the assessment of the quality of care furnished by an
ACO and the establishment of performance standards under
subsection (b)(3);
``(3) the assignment of Medicare fee-for-service
beneficiaries to an ACO under subsection (c);
``(4) the determination of whether an ACO is eligible for
shared savings under subsection (d)(2) and the amount of such
shared savings, including the determination of the estimated
average per capita Medicare expenditures under the ACO for
Medicare fee-for-service beneficiaries assigned to the ACO
and the average benchmark for the ACO under subsection
(d)(1)(B);
``(5) the percent of shared savings specified by the
Secretary under subsection (d)(2) and any limit on the total
amount of shared savings established by the Secretary under
such subsection; and
``(6) the termination of an ACO under subsection (d)(4).
``(h) Definitions.--In this section:
``(1) ACO professional.--The term `ACO professional'
means--
``(A) a physician (as defined in section 1861(r)(1)); and
``(B) a practitioner described in section
1842(b)(18)(C)(i).
``(2) Hospital.--The term `hospital' means a subsection (d)
hospital (as defined in section 1886(d)(1)(B)).
``(3) Medicare fee-for-service beneficiary.--The term
`Medicare fee-for-service beneficiary' means an individual
who is enrolled in the original Medicare fee-for-service
program under parts A and B and is not enrolled in an MA plan
under part C, an eligible organization under section 1876, or
a PACE program under section 1894.''.
SEC. 3023. NATIONAL PILOT PROGRAM ON PAYMENT BUNDLING.
Title XVIII of the Social Security Act, as amended by
section 3021, is amended by inserting after section 1886C the
following new section:
``national pilot program on payment bundling
``Sec. 1866D. (a) Implementation.--
``(1) In general.--The Secretary shall establish a pilot
program for integrated care during an episode of care
provided to an applicable beneficiary around a
hospitalization in order to improve the coordination,
quality, and efficiency of health care services under this
title.
``(2) Definitions.--In this section:
``(A) Applicable beneficiary.--The term `applicable
beneficiary' means an individual who--
``(i) is entitled to, or enrolled for, benefits under part
A and enrolled for benefits under part B of such title, but
not enrolled under part C or a PACE program under section
1894; and
``(ii) is admitted to a hospital for an applicable
condition.
``(B) Applicable condition.--The term `applicable
condition' means 1 or more of 8 conditions selected by the
Secretary. In selecting conditions under the preceding
sentence, the Secretary shall take into consideration the
following factors:
``(i) Whether the conditions selected include a mix of
chronic and acute conditions.
``(ii) Whether the conditions selected include a mix of
surgical and medical conditions.
``(iii) Whether a condition is one for which there is
evidence of an opportunity for providers of services and
suppliers to improve the quality of care furnished while
reducing total expenditures under this title.
``(iv) Whether a condition has significant variation in--
``(I) the number of readmissions; and
``(II) the amount of expenditures for post-acute care
spending under this title.
``(v) Whether a condition is high-volume and has high post-
acute care expenditures under this title.
``(vi) Which conditions the Secretary determines are most
amenable to bundling across the spectrum of care given
practice patterns under this title.
``(C) Applicable services.--The term `applicable services'
means the following:
``(i) Acute care inpatient services.
``(ii) Physicians' services delivered in and outside of an
acute care hospital setting.
``(iii) Outpatient hospital services, including emergency
department services.
``(iv) Post-acute care services, including home health
services, skilled nursing services, inpatient rehabilitation
services, and inpatient hospital services furnished by a
long-term care hospital.
``(v) Other services the Secretary determines appropriate.
``(D) Episode of care.--
``(i) In general.--Subject to clause (ii), the term
`episode of care' means, with respect to an applicable
condition and an applicable beneficiary, the period that
includes--
``(I) the 3 days prior to the admission of the applicable
beneficiary to a hospital for the applicable condition;
``(II) the length of stay of the applicable beneficiary in
such hospital; and
``(III) the 30 days following the discharge of the
applicable beneficiary from such hospital.
``(ii) Establishment of period by the secretary.--The
Secretary, as appropriate, may establish a period (other than
the period described in clause (i)) for an episode of care
under the pilot program.
``(E) Physicians' services.--The term `physicians'
services' has the meaning given such term in section 1861(q).
``(F) Pilot program.--The term `pilot program' means the
pilot program under this section.
``(G) Provider of services.--The term `provider of
services' has the meaning given such term in section 1861(u).
``(H) Readmission.--The term `readmission' has the meaning
given such term in section 1886(q)(5)(E).
``(I) Supplier.--The term `supplier' has the meaning given
such term in section 1861(d).
``(3) Deadline for implementation.--The Secretary shall
establish the pilot program not later than January 1, 2013.
``(b) Developmental Phase.--
``(1) Determination of patient assessment instrument.--The
Secretary shall determine which patient assessment instrument
(such as the Continuity Assessment Record and Evaluation
(CARE) tool) shall be used under the pilot program to
evaluate the applicable condition of an applicable
beneficiary for purposes of determining the most clinically
appropriate site for the provision of post-acute care to the
applicable beneficiary.
``(2) Development of quality measures for an episode of
care and for post-acute care.--
``(A) In general.--The Secretary, in consultation with the
Agency for Healthcare Research and Quality and the entity
with a contract under section 1890(a) of the Social Security
Act, shall develop quality measures for use in the pilot
program--
``(i) for episodes of care; and
``(ii) for post-acute care.
``(B) Site-neutral post-acute care quality measures.--Any
quality measures developed under subparagraph (A)(ii) shall
be site-neutral.
``(C) Coordination with quality measure development and
endorsement procedures.--The Secretary shall ensure that the
development of quality measures under subparagraph (A) is
done in a manner that is consistent with the measures
developed and endorsed under section 1890 and 1890A that are
applicable to all post-acute care settings.
[[Page H1994]]
``(c) Details.--
``(1) Duration.--
``(A) In general.--Subject to subparagraph (B), the pilot
program shall be conducted for a period of 5 years.
``(B) Extension.--The Secretary may extend the duration of
the pilot program for providers of services and suppliers
participating in the pilot program as of the day before the
end of the 5-year period described in subparagraph (A), for a
period determined appropriate by the Secretary, if the
Secretary determines that such extension will result in
improving or not reducing the quality of patient care and
reducing spending under this title.
``(2) Participating providers of services and suppliers.--
``(A) In general.--An entity comprised of providers of
services and suppliers, including a hospital, a physician
group, a skilled nursing facility, and a home health agency,
who are otherwise participating under this title, may submit
an application to the Secretary to provide applicable
services to applicable individuals under this section.
``(B) Requirements.--The Secretary shall develop
requirements for entities to participate in the pilot program
under this section. Such requirements shall ensure that
applicable beneficiaries have an adequate choice of providers
of services and suppliers under the pilot program.
``(3) Payment methodology.--
``(A) In general.--
``(i) Establishment of payment methods.--The Secretary
shall develop payment methods for the pilot program for
entities participating in the pilot program. Such payment
methods may include bundled payments and bids from entities
for episodes of care. The Secretary shall make payments to
the entity for services covered under this section.
``(ii) No additional program expenditures.--Payments under
this section for applicable items and services under this
title (including payment for services described in
subparagraph (B)) for applicable beneficiaries for a year
shall be established in a manner that does not result in
spending more for such entity for such beneficiaries than
would otherwise be expended for such entity for such
beneficiaries for such year if the pilot program were not
implemented, as estimated by the Secretary.
``(B) Inclusion of certain services.--A payment methodology
tested under the pilot program shall include payment for the
furnishing of applicable services and other appropriate
services, such as care coordination, medication
reconciliation, discharge planning, transitional care
services, and other patient-centered activities as determined
appropriate by the Secretary.
``(C) Bundled payments.--
``(i) In general.--A bundled payment under the pilot
program shall--
``(I) be comprehensive, covering the costs of applicable
services and other appropriate services furnished to an
individual during an episode of care (as determined by the
Secretary); and
``(II) be made to the entity which is participating in the
pilot program.
``(ii) Requirement for provision of applicable services and
other appropriate services.--Applicable services and other
appropriate services for which payment is made under this
subparagraph shall be furnished or directed by the entity
which is participating in the pilot program.
``(D) Payment for post-acute care services after the
episode of care.--The Secretary shall establish procedures,
in the case where an applicable beneficiary requires
continued post-acute care services after the last day of the
episode of care, under which payment for such services shall
be made.
``(4) Quality measures.--
``(A) In general.--The Secretary shall establish quality
measures (including quality measures of process, outcome, and
structure) related to care provided by entities participating
in the pilot program. Quality measures established under the
preceding sentence shall include measures of the following:
``(i) Functional status improvement.
``(ii) Reducing rates of avoidable hospital readmissions.
``(iii) Rates of discharge to the community.
``(iv) Rates of admission to an emergency room after a
hospitalization.
``(v) Incidence of health care acquired infections.
``(vi) Efficiency measures.
``(vii) Measures of patient-centeredness of care.
``(viii) Measures of patient perception of care.
``(ix) Other measures, including measures of patient
outcomes, determined appropriate by the Secretary.
``(B) Reporting on quality measures.--
``(i) In general.--A entity shall submit data to the
Secretary on quality measures established under subparagraph
(A) during each year of the pilot program (in a form and
manner, subject to clause (iii), specified by the Secretary).
``(ii) Submission of data through electronic health
record.--To the extent practicable, the Secretary shall
specify that data on measures be submitted under clause (i)
through the use of an qualified electronic health record (as
defined in section 3000(13) of the Public Health Service Act
(42 U.S.C. 300jj-11(13)) in a manner specified by the
Secretary.
``(d) Waiver.--The Secretary may waive such provisions of
this title and title XI as may be necessary to carry out the
pilot program.
``(e) Independent Evaluation and Reports on Pilot
Program.--
``(1) Independent evaluation.--The Secretary shall conduct
an independent evaluation of the pilot program, including the
extent to which the pilot program has--
``(A) improved quality measures established under
subsection (c)(4)(A);
``(B) improved health outcomes;
``(C) improved applicable beneficiary access to care; and
``(D) reduced spending under this title.
``(2) Reports.--
``(A) Interim report.--Not later than 2 years after the
implementation of the pilot program, the Secretary shall
submit to Congress a report on the initial results of the
independent evaluation conducted under paragraph (1).
``(B) Final report.--Not later than 3 years after the
implementation of the pilot program, the Secretary shall
submit to Congress a report on the final results of the
independent evaluation conducted under paragraph (1).
``(f) Consultation.--The Secretary shall consult with
representatives of small rural hospitals, including critical
access hospitals (as defined in section 1861(mm)(1)),
regarding their participation in the pilot program. Such
consultation shall include consideration of innovative
methods of implementing bundled payments in hospitals
described in the preceding sentence, taking into
consideration any difficulties in doing so as a result of the
low volume of services provided by such hospitals.
``(g) Implementation Plan.--
``(1) In general.--Not later than January 1, 2016, the
Secretary shall submit a plan for the implementation of an
expansion of the pilot program if the Secretary determines
that such expansion will result in improving or not reducing
the quality of patient care and reducing spending under this
title.
``(h) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to the selection, testing, and
evaluation of models or the expansion of such models under
this section.''.
SEC. 3024. INDEPENDENCE AT HOME DEMONSTRATION PROGRAM.
Title XVIII of the Social Security Act is amended by
inserting after section 1866D, as inserted by section 3023,
the following new section:
``independence at home medical practice demonstration program
``Sec. 1866D. (a) Establishment.--
``(1) In general.--The Secretary shall conduct a
demonstration program (in this section referred to as the
`demonstration program') to test a payment incentive and
service delivery model that utilizes physician and nurse
practitioner directed home-based primary care teams designed
to reduce expenditures and improve health outcomes in the
provision of items and services under this title to
applicable beneficiaries (as defined in subsection (d)).
``(2) Requirement.--The demonstration program shall test
whether a model described in paragraph (1), which is
accountable for providing comprehensive, coordinated,
continuous, and accessible care to high-need populations at
home and coordinating health care across all treatment
settings, results in--
``(A) reducing preventable hospitalizations;
``(B) preventing hospital readmissions;
``(C) reducing emergency room visits;
``(D) improving health outcomes commensurate with the
beneficiaries' stage of chronic illness;
``(E) improving the efficiency of care, such as by reducing
duplicative diagnostic and laboratory tests;
``(F) reducing the cost of health care services covered
under this title; and
``(G) achieving beneficiary and family caregiver
satisfaction.
``(b) Independence at Home Medical Practice.--
``(1) Independence at home medical practice defined.--In
this section:
``(A) In general.--The term `independence at home medical
practice' means a legal entity that--
``(i) is comprised of an individual physician or nurse
practitioner or group of physicians and nurse practitioners
that provides care as part of a team that includes
physicians, nurses, physician assistants, pharmacists, and
other health and social services staff as appropriate who
have experience providing home-based primary care to
applicable beneficiaries, make in-home visits, and are
available 24 hours per day, 7 days per week to carry out
plans of care that are tailored to the individual
beneficiary's chronic conditions and designed to achieve the
results in subsection (a);
``(ii) is organized at least in part for the purpose of
providing physicians' services;
``(iii) has documented experience in providing home-based
primary care services to high-cost chronically ill
beneficiaries, as determined appropriate by the Secretary;
``(iv) furnishes services to at least 200 applicable
beneficiaries (as defined in subsection (d)) during each year
of the demonstration program;
``(v) has entered into an agreement with the Secretary;
``(vi) uses electronic health information systems, remote
monitoring, and mobile diagnostic technology; and
``(vii) meets such other criteria as the Secretary
determines to be appropriate to participate in the
demonstration program.
The entity shall report on quality measures (in such form,
manner, and frequency as specified by the Secretary, which
may be for the group, for providers of services and
suppliers, or both) and report to the Secretary (in a form,
manner, and frequency as specified by the Secretary) such
data as the Secretary determines appropriate to monitor and
evaluate the demonstration program.
``(B) Physician.--The term `physician' includes, except as
the Secretary may otherwise provide, any individual who
furnishes services for which payment may be made as
physicians' services and has the medical training or
experience to fulfill the physician's role described in
subparagraph (A)(i).
[[Page H1995]]
``(2) Participation of nurse practitioners and physician
assistants.--Nothing in this section shall be construed to
prevent a nurse practitioner or physician assistant from
participating in, or leading, a home-based primary care team
as part of an independence at home medical practice if--
``(A) all the requirements of this section are met;
``(B) the nurse practitioner or physician assistant, as the
case may be, is acting consistent with State law; and
``(C) the nurse practitioner or physician assistant has the
medical training or experience to fulfill the nurse
practitioner or physician assistant role described in
paragraph (1)(A)(i).
``(3) Inclusion of providers and practitioners.--Nothing in
this subsection shall be construed as preventing an
independence at home medical practice from including a
provider of services or a participating practitioner
described in section 1842(b)(18)(C) that is affiliated with
the practice under an arrangement structured so that such
provider of services or practitioner participates in the
demonstration program and shares in any savings under the
demonstration program.
``(4) Quality and performance standards.--The Secretary
shall develop quality performance standards for independence
at home medical practices participating in the demonstration
program.
``(c) Payment Methodology.--
``(1) Establishment of target spending level.--The
Secretary shall establish an estimated annual spending
target, for the amount the Secretary estimates would have
been spent in the absence of the demonstration, for items and
services covered under parts A and B furnished to applicable
beneficiaries for each qualifying independence at home
medical practice under this section. Such spending targets
shall be determined on a per capita basis. Such spending
targets shall include a risk corridor that takes into account
normal variation in expenditures for items and services
covered under parts A and B furnished to such beneficiaries
with the size of the corridor being related to the number of
applicable beneficiaries furnished services by each
independence at home medical practice. The spending targets
may also be adjusted for other factors as the Secretary
determines appropriate.
``(2) Incentive payments.--Subject to performance on
quality measures, a qualifying independence at home medical
practice is eligible to receive an incentive payment under
this section if actual expenditures for a year for the
applicable beneficiaries it enrolls are less than the
estimated spending target established under paragraph (1) for
such year. An incentive payment for such year shall be equal
to a portion (as determined by the Secretary) of the amount
by which actual expenditures (including incentive payments
under this paragraph) for applicable beneficiaries under
parts A and B for such year are estimated to be less than 5
percent less than the estimated spending target for such
year, as determined under paragraph (1).
``(d) Applicable Beneficiaries.--
``(1) Definition.--In this section, the term `applicable
beneficiary' means, with respect to a qualifying independence
at home medical practice, an individual who the practice has
determined--
``(A) is entitled to benefits under part A and enrolled for
benefits under part B;
``(B) is not enrolled in a Medicare Advantage plan under
part C or a PACE program under section 1894;
``(C) has 2 or more chronic illnesses, such as congestive
heart failure, diabetes, other dementias designated by the
Secretary, chronic obstructive pulmonary disease, ischemic
heart disease, stroke, Alzheimer's Disease and
neurodegenerative diseases, and other diseases and conditions
designated by the Secretary which result in high costs under
this title;
``(D) within the past 12 months has had a nonelective
hospital admission;
``(E) within the past 12 months has received acute or
subacute rehabilitation services;
``(F) has 2 or more functional dependencies requiring the
assistance of another person (such as bathing, dressing,
toileting, walking, or feeding); and
``(G) meets such other criteria as the Secretary determines
appropriate.
``(2) Patient election to participate.--The Secretary shall
determine an appropriate method of ensuring that applicable
beneficiaries have agreed to enroll in an independence at
home medical practice under the demonstration program.
Enrollment in the demonstration program shall be voluntary.
``(3) Beneficiary access to services.--Nothing in this
section shall be construed as encouraging physicians or nurse
practitioners to limit applicable beneficiary access to
services covered under this title and applicable
beneficiaries shall not be required to relinquish access to
any benefit under this title as a condition of receiving
services from an independence at home medical practice.
``(e) Implementation.--
``(1) Starting date.--The demonstration program shall begin
no later than January 1, 2012. An agreement with an
independence at home medical practice under the demonstration
program may cover not more than a 3-year period.
``(2) No physician duplication in demonstration
participation.--The Secretary shall not pay an independence
at home medical practice under this section that participates
in section 1899.
``(3) No beneficiary duplication in demonstration
participation.--The Secretary shall ensure that no applicable
beneficiary enrolled in an independence at home medical
practice under this section is participating in the programs
under section 1899.
``(4) Preference.--In approving an independence at home
medical practice, the Secretary shall give preference to
practices that are--
``(A) located in high-cost areas of the country;
``(B) have experience in furnishing health care services to
applicable beneficiaries in the home; and
``(C) use electronic medical records, health information
technology, and individualized plans of care.
``(5) Limitation on number of practices.--In selecting
qualified independence at home medical practices to
participate under the demonstration program, the Secretary
shall limit the number of such practices so that the number
of applicable beneficiaries that may participate in the
demonstration program does not exceed 10,000.
``(6) Waiver.--The Secretary may waive such provisions of
this title and title XI as the Secretary determines necessary
in order to implement the demonstration program.
``(7) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to this section.
``(f) Evaluation and Monitoring.--
``(1) In general.--The Secretary shall evaluate each
independence at home medical practice under the demonstration
program to assess whether the practice achieved the results
described in subsection (a).
``(2) Monitoring applicable beneficiaries.--The Secretary
may monitor data on expenditures and quality of services
under this title after an applicable beneficiary discontinues
receiving services under this title through a qualifying
independence at home medical practice.
``(g) Reports to Congress.--The Secretary shall conduct an
independent evaluation of the demonstration program and
submit to Congress a final report, including best practices
under the demonstration program. Such report shall include an
analysis of the demonstration program on coordination of
care, expenditures under this title, applicable beneficiary
access to services, and the quality of health care services
provided to applicable beneficiaries.
``(h) Funding.--For purposes of administering and carrying
out the demonstration program, other than for payments for
items and services furnished under this title and incentive
payments under subsection (c), in addition to funds otherwise
appropriated, there shall be transferred to the Secretary for
the Center for Medicare & Medicaid Services Program
Management Account from the Federal Hospital Insurance Trust
Fund under section 1817 and the Federal Supplementary Medical
Insurance Trust Fund under section 1841 (in proportions
determined appropriate by the Secretary) $5,000,000 for each
of fiscal years 2010 through 2015. Amounts transferred under
this subsection for a fiscal year shall be available until
expended.
``(i) Termination.--
``(1) Mandatory termination.--The Secretary shall terminate
an agreement with an independence at home medical practice
if--
``(A) the Secretary estimates or determines that such
practice will not receive an incentive payment for the second
of 2 consecutive years under the demonstration program; or
``(B) such practice fails to meet quality standards during
any year of the demonstration program.
``(2) Permissive termination.--The Secretary may terminate
an agreement with an independence at home medical practice
for such other reasons determined appropriate by the
Secretary.''.
SEC. 3025. HOSPITAL READMISSIONS REDUCTION PROGRAM.
(a) In General.--Section 1886 of the Social Security Act
(42 U.S.C. 1395ww), as amended by sections 3001 and 3008, is
amended by adding at the end the following new subsection:
``(q) Hospital Readmissions Reduction Program.--
``(1) In general.--With respect to payment for discharges
from an applicable hospital (as defined in paragraph (5)(C))
occurring during a fiscal year beginning on or after October
1, 2012, in order to account for excess readmissions in the
hospital, the Secretary shall reduce the payments that would
otherwise be made to such hospital under subsection (d) (or
section 1814(b)(3), as the case may be) for such a discharge
by an amount equal to the product of--
``(A) the base operating DRG payment amount (as defined in
paragraph (2)) for the discharge; and
``(B) the adjustment factor (described in paragraph (3)(A))
for the hospital for the fiscal year.
``(2) Base operating drg payment amount defined.--
``(A) In general.--Except as provided in subparagraph (B),
in this subsection, the term `base operating DRG payment
amount' means, with respect to a hospital for a fiscal year--
``(i) the payment amount that would otherwise be made under
subsection (d) (determined without regard to subsection (o))
for a discharge if this subsection did not apply; reduced by
``(ii) any portion of such payment amount that is
attributable to payments under paragraphs (5)(A), (5)(B),
(5)(F), and (12) of subsection (d).
``(B) Special rules for certain hospitals.--
``(i) Sole community hospitals and medicare-dependent,
small rural hospitals.--In the case of a medicare-dependent,
small rural hospital (with respect to discharges occurring
during fiscal years 2012 and 2013) or a sole community
hospital, in applying subparagraph (A)(i), the payment amount
that would otherwise be made under subsection (d) shall be
determined without regard to subparagraphs (I) and (L) of
subsection (b)(3) and subparagraphs (D) and (G) of subsection
(d)(5).
``(ii) Hospitals paid under section 1814.--In the case of a
hospital that is paid under section 1814(b)(3), the Secretary
may exempt such hospitals provided that States paid under
such section submit an annual report to the Secretary
[[Page H1996]]
describing how a similar program in the State for a
participating hospital or hospitals achieves or surpasses the
measured results in terms of patient health outcomes and cost
savings established herein with respect to this section.
``(3) Adjustment factor.--
``(A) In general.--For purposes of paragraph (1), the
adjustment factor under this paragraph for an applicable
hospital for a fiscal year is equal to the greater of--
``(i) the ratio described in subparagraph (B) for the
hospital for the applicable period (as defined in paragraph
(5)(D)) for such fiscal year; or
``(ii) the floor adjustment factor specified in
subparagraph (C).
``(B) Ratio.--The ratio described in this subparagraph for
a hospital for an applicable period is equal to 1 minus the
ratio of--
``(i) the aggregate payments for excess readmissions (as
defined in paragraph (4)(A)) with respect to an applicable
hospital for the applicable period; and
``(ii) the aggregate payments for all discharges (as
defined in paragraph (4)(B)) with respect to such applicable
hospital for such applicable period.
``(C) Floor adjustment factor.--For purposes of
subparagraph (A), the floor adjustment factor specified in
this subparagraph for--
``(i) fiscal year 2013 is 0.99;
``(ii) fiscal year 2014 is 0.98; or
``(iii) fiscal year 2015 and subsequent fiscal years is
0.97.
``(4) Aggregate payments, excess readmission ratio
defined.--For purposes of this subsection:
``(A) Aggregate payments for excess readmissions.--The term
`aggregate payments for excess readmissions' means, for a
hospital for an applicable period, the sum, for applicable
conditions (as defined in paragraph (5)(A)), of the product,
for each applicable condition, of--
``(i) the base operating DRG payment amount for such
hospital for such applicable period for such condition;
``(ii) the number of admissions for such condition for such
hospital for such applicable period; and
``(iii) the excess readmissions ratio (as defined in
subparagraph (C)) for such hospital for such applicable
period minus 1.
``(B) Aggregate payments for all discharges.--The term
`aggregate payments for all discharges' means, for a hospital
for an applicable period, the sum of the base operating DRG
payment amounts for all discharges for all conditions from
such hospital for such applicable period.
``(C) Excess readmission ratio.--
``(i) In general.--Subject to clause (ii), the term `excess
readmissions ratio' means, with respect to an applicable
condition for a hospital for an applicable period, the ratio
(but not less than 1.0) of--
``(I) the risk adjusted readmissions based on actual
readmissions, as determined consistent with a readmission
measure methodology that has been endorsed under paragraph
(5)(A)(ii)(I), for an applicable hospital for such condition
with respect to such applicable period; to
``(II) the risk adjusted expected readmissions (as
determined consistent with such a methodology) for such
hospital for such condition with respect to such applicable
period.
``(ii) Exclusion of certain readmissions.--For purposes of
clause (i), with respect to a hospital, excess readmissions
shall not include readmissions for an applicable condition
for which there are fewer than a minimum number (as
determined by the Secretary) of discharges for such
applicable condition for the applicable period and such
hospital.
``(5) Definitions.--For purposes of this subsection:
``(A) Applicable condition.--The term `applicable
condition' means, subject to subparagraph (B), a condition or
procedure selected by the Secretary among conditions and
procedures for which--
``(i) readmissions (as defined in subparagraph (E)) that
represent conditions or procedures that are high volume or
high expenditures under this title (or other criteria
specified by the Secretary); and
``(ii) measures of such readmissions--
``(I) have been endorsed by the entity with a contract
under section 1890(a); and
``(II) such endorsed measures have exclusions for
readmissions that are unrelated to the prior discharge (such
as a planned readmission or transfer to another applicable
hospital).
``(B) Expansion of applicable conditions.--Beginning with
fiscal year 2015, the Secretary shall, to the extent
practicable, expand the applicable conditions beyond the 3
conditions for which measures have been endorsed as described
in subparagraph (A)(ii)(I) as of the date of the enactment of
this subsection to the additional 4 conditions that have been
identified by the Medicare Payment Advisory Commission in its
report to Congress in June 2007 and to other conditions and
procedures as determined appropriate by the Secretary. In
expanding such applicable conditions, the Secretary shall
seek the endorsement described in subparagraph (A)(ii)(I) but
may apply such measures without such an endorsement in the
case of a specified area or medical topic determined
appropriate by the Secretary for which a feasible and
practical measure has not been endorsed by the entity with a
contract under section 1890(a) as long as due consideration
is given to measures that have been endorsed or adopted by a
consensus organization identified by the Secretary.
``(C) Applicable hospital.--The term `applicable hospital'
means a subsection (d) hospital or a hospital that is paid
under section 1814(b)(3), as the case may be.
``(D) Applicable period.--The term `applicable period'
means, with respect to a fiscal year, such period as the
Secretary shall specify.
``(E) Readmission.--The term `readmission' means, in the
case of an individual who is discharged from an applicable
hospital, the admission of the individual to the same or
another applicable hospital within a time period specified by
the Secretary from the date of such discharge. Insofar as the
discharge relates to an applicable condition for which there
is an endorsed measure described in subparagraph (A)(ii)(I),
such time period (such as 30 days) shall be consistent with
the time period specified for such measure.
``(6) Reporting hospital specific information.--
``(A) In general.--The Secretary shall make information
available to the public regarding readmission rates of each
subsection (d) hospital under the program.
``(B) Opportunity to review and submit corrections.--The
Secretary shall ensure that a subsection (d) hospital has the
opportunity to review, and submit corrections for, the
information to be made public with respect to the hospital
under subparagraph (A) prior to such information being made
public.
``(C) Website.--Such information shall be posted on the
Hospital Compare Internet website in an easily understandable
format.
``(7) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of the following:
``(A) The determination of base operating DRG payment
amounts.
``(B) The methodology for determining the adjustment factor
under paragraph (3), including excess readmissions ratio
under paragraph (4)(C), aggregate payments for excess
readmissions under paragraph (4)(A), and aggregate payments
for all discharges under paragraph (4)(B), and applicable
periods and applicable conditions under paragraph (5).
``(C) The measures of readmissions as described in
paragraph (5)(A)(ii).
``(8) Readmission rates for all patients.--
``(A) Calculation of readmission.--The Secretary shall
calculate readmission rates for all patients (as defined in
subparagraph (D)) for a specified hospital (as defined in
subparagraph (D)(ii)) for an applicable condition (as defined
in paragraph (5)(B)) and other conditions deemed appropriate
by the Secretary for an applicable period (as defined in
paragraph (5)(D)) in the same manner as used to calculate
such readmission rates for hospitals with respect to this
title and posted on the CMS Hospital Compare website.
``(B) Posting of hospital specific all patient readmission
rates.--The Secretary shall make information on all patient
readmission rates calculated under subparagraph (A) available
on the CMS Hospital Compare website in a form and manner
determined appropriate by the Secretary. The Secretary may
also make other information determined appropriate by the
Secretary available on such website.
``(C) Hospital submission of all patient data.--
``(i) Except as provided for in clause (ii), each specified
hospital (as defined in subparagraph (D)(ii)) shall submit to
the Secretary, in a form, manner and time specified by the
Secretary, data and information determined necessary by the
Secretary for the Secretary to calculate the all patient
readmission rates described in subparagraph (A).
``(ii) Instead of a specified hospital submitting to the
Secretary the data and information described in clause (i),
such data and information may be submitted to the Secretary,
on behalf of such a specified hospital, by a state or an
entity determined appropriate by the Secretary.
``(D) Definitions.--For purposes of this paragraph:
``(i) The term `all patients' means patients who are
treated on an inpatient basis and discharged from a specified
hospital (as defined in clause (ii)).
``(ii) The term `specified hospital' means a subsection (d)
hospital, hospitals described in clauses (i) through (v) of
subsection (d)(1)(B) and, as determined feasible and
appropriate by the Secretary, other hospitals not otherwise
described in this subparagraph.''.
(b) Quality Improvement.--Part S of title III of the Public
Health Service Act, as amended by section 3015, is further
amended by adding at the end the following:
``SEC. 399KK. QUALITY IMPROVEMENT PROGRAM FOR HOSPITALS WITH
A HIGH SEVERITY ADJUSTED READMISSION RATE.
``(a) Establishment.--
``(1) In general.--Not later than 2 years after the date of
enactment of this section, the Secretary shall make available
a program for eligible hospitals to improve their readmission
rates through the use of patient safety organizations (as
defined in section 921(4)).
``(2) Eligible hospital defined.--In this subsection, the
term `eligible hospital' means a hospital that the Secretary
determines has a high rate of risk adjusted readmissions for
the conditions described in section 1886(q)(8)(A) of the
Social Security Act and has not taken appropriate steps to
reduce such readmissions and improve patient safety as
evidenced through historically high rates of readmissions, as
determined by the Secretary.
``(3) Risk adjustment.--The Secretary shall utilize
appropriate risk adjustment measures to determine eligible
hospitals.
``(b) Report to the Secretary.--As determined appropriate
by the Secretary, eligible hospitals and patient safety
organizations working with those hospitals shall report to
the Secretary on the processes employed by the hospital to
improve readmission rates and the impact of such processes on
readmission rates.''.
[[Page H1997]]
SEC. 3026. COMMUNITY-BASED CARE TRANSITIONS PROGRAM.
(a) In General.--The Secretary shall establish a Community-
Based Care Transitions Program under which the Secretary
provides funding to eligible entities that furnish improved
care transition services to high-risk Medicare beneficiaries.
(b) Definitions.--In this section:
(1) Eligible entity.--The term ``eligible entity'' means
the following:
(A) A subsection (d) hospital (as defined in section
1886(d)(1)(B) of the Social Security Act (42 U.S.C.
1395ww(d)(1)(B))) identified by the Secretary as having a
high readmission rate, such as under section 1886(q) of the
Social Security Act, as added by section 3025.
(B) An appropriate community-based organization that
provides care transition services under this section across a
continuum of care through arrangements with subsection (d)
hospitals (as so defined) to furnish the services described
in subsection (c)(2)(B)(i) and whose governing body includes
sufficient representation of multiple health care
stakeholders (including consumers).
(2) High-risk medicare beneficiary.--The term ``high-risk
Medicare beneficiary'' means a Medicare beneficiary who has
attained a minimum hierarchical condition category score, as
determined by the Secretary, based on a diagnosis of multiple
chronic conditions or other risk factors associated with a
hospital readmission or substandard transition into post-
hospitalization care, which may include 1 or more of the
following:
(A) Cognitive impairment.
(B) Depression.
(C) A history of multiple readmissions.
(D) Any other chronic disease or risk factor as determined
by the Secretary.
(3) Medicare beneficiary.--The term ``Medicare
beneficiary'' means an individual who is entitled to benefits
under part A of title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) and enrolled under part B of such title,
but not enrolled under part C of such title.
(4) Program.--The term ``program'' means the program
conducted under this section.
(5) Readmission.--The term ``readmission'' has the meaning
given such term in section 1886(q)(5)(E) of the Social
Security Act, as added by section 3025.
(6) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(c) Requirements.--
(1) Duration.--
(A) In general.--The program shall be conducted for a 5-
year period, beginning January 1, 2011.
(B) Expansion.--The Secretary may expand the duration and
the scope of the program, to the extent determined
appropriate by the Secretary, if the Secretary determines
(and the Chief Actuary of the Centers for Medicare & Medicaid
Services, with respect to spending under this title,
certifies) that such expansion would reduce spending under
this title without reducing quality.
(2) Application; participation.--
(A) In general.--
(i) Application.--An eligible entity seeking to participate
in the program shall submit an application to the Secretary
at such time, in such manner, and containing such information
as the Secretary may require.
(ii) Partnership.--If an eligible entity is a hospital,
such hospital shall enter into a partnership with a
community-based organization to participate in the program.
(B) Intervention proposal.--Subject to subparagraph (C), an
application submitted under subparagraph (A)(i) shall include
a detailed proposal for at least 1 care transition
intervention, which may include the following:
(i) Initiating care transition services for a high-risk
Medicare beneficiary not later than 24 hours prior to the
discharge of the beneficiary from the eligible entity.
(ii) Arranging timely post-discharge follow-up services to
the high-risk Medicare beneficiary to provide the beneficiary
(and, as appropriate, the primary caregiver of the
beneficiary) with information regarding responding to
symptoms that may indicate additional health problems or a
deteriorating condition.
(iii) Providing the high-risk Medicare beneficiary (and, as
appropriate, the primary caregiver of the beneficiary) with
assistance to ensure productive and timely interactions
between patients and post-acute and outpatient providers.
(iv) Assessing and actively engaging with a high-risk
Medicare beneficiary (and, as appropriate, the primary
caregiver of the beneficiary) through the provision of self-
management support and relevant information that is specific
to the beneficiary's condition.
(v) Conducting comprehensive medication review and
management (including, if appropriate, counseling and self-
management support).
(C) Limitation.--A care transition intervention proposed
under subparagraph (B) may not include payment for services
required under the discharge planning process described in
section 1861(ee) of the Social Security Act (42 U.S.C.
1395x(ee)).
(3) Selection.--In selecting eligible entities to
participate in the program, the Secretary shall give priority
to eligible entities that--
(A) participate in a program administered by the
Administration on Aging to provide concurrent care
transitions interventions with multiple hospitals and
practitioners; or
(B) provide services to medically underserved populations,
small communities, and rural areas.
(d) Implementation.--Notwithstanding any other provision of
law, the Secretary may implement the provisions of this
section by program instruction or otherwise.
(e) Waiver Authority.--The Secretary may waive such
requirements of titles XI and XVIII of the Social Security
Act as may be necessary to carry out the program.
(f) Funding.--For purposes of carrying out this section,
the Secretary of Health and Human Services shall provide for
the transfer, from the Federal Hospital Insurance Trust Fund
under section 1817 of the Social Security Act (42 U.S.C.
1395i) and the Federal Supplementary Medical Insurance Trust
Fund under section 1841 of such Act (42 U.S.C. 1395t), in
such proportion as the Secretary determines appropriate, of
$500,000,000, to the Centers for Medicare & Medicaid Services
Program Management Account for the period of fiscal years
2011 through 2015. Amounts transferred under the preceding
sentence shall remain available until expended.
SEC. 3027. EXTENSION OF GAINSHARING DEMONSTRATION.
(a) In General.--Subsection (d)(3) of section 5007 of the
Deficit Reduction Act of 2005 (Public Law 109-171) is amended
by inserting ``(or September 30, 2011, in the case of a
demonstration project in operation as of October 1, 2008)''
after ``December 31, 2009''.
(b) Funding.--
(1) In general.--Subsection (f)(1) of such section is
amended by inserting ``and for fiscal year 2010,
$1,600,000,'' after ``$6,000,000,''.
(2) Availability.--Subsection (f)(2) of such section is
amended by striking ``2010'' and inserting ``2014 or until
expended''.
(c) Reports.--
(1) Quality improvement and savings.--Subsection (e)(3) of
such section is amended by striking ``December 1, 2008'' and
inserting ``March 31, 2011''.
(2) Final report.--Subsection (e)(4) of such section is
amended by striking ``May 1, 2010'' and inserting ``March 31,
2013''.
Subtitle B--Improving Medicare for Patients and Providers
PART I--ENSURING BENEFICIARY ACCESS TO PHYSICIAN CARE AND OTHER
SERVICES
SEC. 3101. INCREASE IN THE PHYSICIAN PAYMENT UPDATE.
Section 1848(d) of the Social Security Act (42 U.S.C.
1395w-4(d)) is amended by adding at the end the following new
paragraph:
``(10) Update for 2010.--
``(A) In general.--Subject to paragraphs (7)(B), (8)(B),
and (9)(B), in lieu of the update to the single conversion
factor established in paragraph (1)(C) that would otherwise
apply for 2010, the update to the single conversion factor
shall be 0.5 percent.
``(B) No effect on computation of conversion factor for
2011 and subsequent years.--The conversion factor under this
subsection shall be computed under paragraph (1)(A) for 2011
and subsequent years as if subparagraph (A) had never
applied.''.
SEC. 3102. EXTENSION OF THE WORK GEOGRAPHIC INDEX FLOOR AND
REVISIONS TO THE PRACTICE EXPENSE GEOGRAPHIC
ADJUSTMENT UNDER THE MEDICARE PHYSICIAN FEE
SCHEDULE.
(a) Extension of Work GPCI Floor.--Section 1848(e)(1)(E) of
the Social Security Act (42 U.S.C. 1395w-4(e)(1)(E)) is
amended by striking ``before January 1, 2010'' and inserting
``before January 1, 2011''.
(b) Practice Expense Geographic Adjustment for 2010 and
Subsequent Years.--Section 1848(e)(1) of the Social Security
Act (42 U.S.C. 1395w4(e)(1)) is amended--
(1) in subparagraph (A), by striking ``and (G)'' and
inserting ``(G), and (H)''; and
(2) by adding at the end the following new subparagraph:
``(H) Practice expense geographic adjustment for 2010 and
subsequent years.--
``(i) For 2010.--Subject to clause (iii), for services
furnished during 2010, the employee wage and rent portions of
the practice expense geographic index described in
subparagraph (A)(i) shall reflect \3/4\ of the difference
between the relative costs of employee wages and rents in
each of the different fee schedule areas and the national
average of such employee wages and rents.
``(ii) For 2011.--Subject to clause (iii), for services
furnished during 2011, the employee wage and rent portions of
the practice expense geographic index described in
subparagraph (A)(i) shall reflect \1/2\ of the difference
between the relative costs of employee wages and rents in
each of the different fee schedule areas and the national
average of such employee wages and rents.
``(iii) Hold harmless.--The practice expense portion of the
geographic adjustment factor applied in a fee schedule area
for services furnished in 2010 or 2011 shall not, as a result
of the application of clause (i) or (ii), be reduced below
the practice expense portion of the geographic adjustment
factor under subparagraph (A)(i) (as calculated prior to the
application of such clause (i) or (ii), respectively) for
such area for such year.
``(iv) Analysis.--The Secretary shall analyze current
methods of establishing practice expense geographic
adjustments under subparagraph (A)(i) and evaluate data that
fairly and reliably establishes distinctions in the costs of
operating a medical practice in the different fee schedule
areas. Such analysis shall include an evaluation of the
following:
``(I) The feasibility of using actual data or reliable
survey data developed by medical organizations on the costs
of operating a medical practice, including office rents and
non-physician staff wages, in different fee schedule areas.
``(II) The office expense portion of the practice expense
geographic adjustment described in subparagraph (A)(i),
including the extent to
[[Page H1998]]
which types of office expenses are determined in local
markets instead of national markets.
``(III) The weights assigned to each of the categories
within the practice expense geographic adjustment described
in subparagraph (A)(i).
``(v) Revision for 2012 and subsequent years.--As a result
of the analysis described in clause (iv), the Secretary
shall, not later than January 1, 2012, make appropriate
adjustments to the practice expense geographic adjustment
described in subparagraph (A)(i) to ensure accurate
geographic adjustments across fee schedule areas, including--
``(I) basing the office rents component and its weight on
office expenses that vary among fee schedule areas; and
``(II) considering a representative range of professional
and non-professional personnel employed in a medical office
based on the use of the American Community Survey data or
other reliable data for wage adjustments.
Such adjustments shall be made without regard to adjustments
made pursuant to clauses (i) and (ii) and shall be made in a
budget neutral manner.''.
SEC. 3103. EXTENSION OF EXCEPTIONS PROCESS FOR MEDICARE
THERAPY CAPS.
Section 1833(g)(5) of the Social Security Act (42 U.S.C.
1395l(g)(5)) is amended by striking ``December 31, 2009'' and
inserting ``December 31, 2010''.
SEC. 3104. EXTENSION OF PAYMENT FOR TECHNICAL COMPONENT OF
CERTAIN PHYSICIAN PATHOLOGY SERVICES.
Section 542(c) of the Medicare, Medicaid, and SCHIP
Benefits Improvement and Protection Act of 2000 (as enacted
into law by section 1(a)(6) of Public Law 106-554), as
amended by section 732 of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (42 U.S.C. 1395w-4
note), section 104 of division B of the Tax Relief and Health
Care Act of 2006 (42 U.S.C. 1395w-4 note), section 104 of the
Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public
Law 110-173), and section 136 of the Medicare Improvements
for Patients and Providers Act of 2008 (Public Law 110-275),
is amended by striking ``and 2009'' and inserting ``2009, and
2010''.
SEC. 3105. EXTENSION OF AMBULANCE ADD-ONS.
(a) Ground Ambulance.--Section 1834(l)(13)(A) of the Social
Security Act (42 U.S.C. 1395m(l)(13)(A)) is amended--
(1) in the matter preceding clause (i)--
(A) by striking ``2007, and for'' and inserting ``2007,
for''; and
(B) by striking ``2010'' and inserting ``2010, and for such
services furnished on or after April 1, 2010, and before
January 1, 2011,''; and
(2) in each of clauses (i) and (ii), by inserting ``, and
on or after April 1, 2010, and before January 1, 2011'' after
``January 1, 2010'' each place it appears.
(b) Air Ambulance.--Section 146(b)(1) of the Medicare
Improvements for Patients and Providers Act of 2008 (Public
Law 110-275) is amended by striking ``December 31, 2009'' and
inserting ``December 31, 2009, and during the period
beginning on April 1, 2010, and ending on January 1, 2011''.
(c) Super Rural Ambulance.--Section 1834(l)(12)(A) of the
Social Security Act (42 U.S.C. 1395m(l)(12)(A)) is amended by
striking ``2010'' and inserting ``2010, and on or after April
1, 2010, and before January 1, 2011''.
SEC. 3106. EXTENSION OF CERTAIN PAYMENT RULES FOR LONG-TERM
CARE HOSPITAL SERVICES AND OF MORATORIUM ON THE
ESTABLISHMENT OF CERTAIN HOSPITALS AND
FACILITIES.
(a) Extension of Certain Payment Rules.--Section 114(c) of
the Medicare, Medicaid, and SCHIP Extension Act of 2007 (42
U.S.C. 1395ww note), as amended by section 4302(a) of the
American Recovery and Reinvestment Act (Public Law 111-5), is
further amended by striking ``3-year period'' each place it
appears and inserting ``4-year period''.
(b) Extension of Moratorium.--Section 114(d)(1) of such Act
(42 U.S.C. 1395ww note), in the matter preceding subparagraph
(A), is amended by striking ``3-year period'' and inserting
``4-year period''.
SEC. 3107. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL HEALTH
ADD-ON.
Section 138(a)(1) of the Medicare Improvements for Patients
and Providers Act of 2008 (Public Law 110-275) is amended by
striking ``December 31, 2009'' and inserting ``December 31,
2010''.
SEC. 3108. PERMITTING PHYSICIAN ASSISTANTS TO ORDER POST-
HOSPITAL EXTENDED CARE SERVICES.
(a) Ordering Post-Hospital Extended Care Services.--
(1) In general.--Section 1814(a)(2) of the Social Security
Act (42 U.S.C. 1395f(a)(2)), in the matter preceding
subparagraph (A), is amended by striking ``or clinical nurse
specialist'' and inserting ``, a clinical nurse specialist,
or a physician assistant (as those terms are defined in
section 1861(aa)(5))'' after ``nurse practitioner''.
(2) Conforming amendment.--Section 1814(a) of the Social
Security Act (42 U.S.C. 1395f(a)) is amended, in the second
sentence, by striking ``or clinical nurse specialist'' and
inserting ``clinical nurse specialist, or physician
assistant'' after ``nurse practitioner,''.
(b) Effective Date.--The amendments made by this section
shall apply to items and services furnished on or after
January 1, 2011.
SEC. 3109. EXEMPTION OF CERTAIN PHARMACIES FROM ACCREDITATION
REQUIREMENTS.
(a) In General.--Section 1834(a)(20) of the Social Security
Act (42 U.S.C. 1395m(a)(20)), as added by section
154(b)(1)(A) of the Medicare Improvements for Patients and
Providers Act of 2008 (Public Law 100-275), is amended--
(1) in subparagraph (F)(i)--
(A) by inserting ``and subparagraph (G)'' after ``clause
(ii)''; and
(B) by inserting ``, except that the Secretary shall not
require a pharmacy to have submitted to the Secretary such
evidence of accreditation prior to January 1, 2011'' before
the semicolon at the end; and
(2) by adding at the end the following new subparagraph:
``(G) Application of accreditation requirement to certain
pharmacies.--
``(i) In general.--With respect to items and services
furnished on or after January 1, 2011, in implementing
quality standards under this paragraph--
``(I) subject to subclause (II), in applying such standards
and the accreditation requirement of subparagraph (F)(i) with
respect to pharmacies described in clause (ii) furnishing
such items and services, such standards and accreditation
requirement shall not apply to such pharmacies; and
``(II) the Secretary may apply to such pharmacies an
alternative accreditation requirement established by the
Secretary if the Secretary determines such alternative
accreditation requirement is more appropriate for such
pharmacies.
``(ii) Pharmacies described.--A pharmacy described in this
clause is a pharmacy that meets each of the following
criteria:
``(I) The total billings by the pharmacy for such items and
services under this title are less than 5 percent of total
pharmacy sales, as determined based on the average total
pharmacy sales for the previous 3 calendar years, 3 fiscal
years, or other yearly period specified by the Secretary.
``(II) The pharmacy has been enrolled under section 1866(j)
as a supplier of durable medical equipment, prosthetics,
orthotics, and supplies, has been issued (which may include
the renewal of) a provider number for at least 5 years, and
for which a final adverse action (as defined in section
424.57(a) of title 42, Code of Federal Regulations) has not
been imposed in the past 5 years.
``(III) The pharmacy submits to the Secretary an
attestation, in a form and manner, and at a time, specified
by the Secretary, that the pharmacy meets the criteria
described in subclauses (I) and (II). Such attestation shall
be subject to section 1001 of title 18, United States Code.
``(IV) The pharmacy agrees to submit materials as requested
by the Secretary, or during the course of an audit conducted
on a random sample of pharmacies selected annually, to verify
that the pharmacy meets the criteria described in subclauses
(I) and (II). Materials submitted under the preceding
sentence shall include a certification by an accountant on
behalf of the pharmacy or the submission of tax returns filed
by the pharmacy during the relevant periods, as requested by
the Secretary.''.
(b) Administration.--Notwithstanding any other provision of
law, the Secretary may implement the amendments made by
subsection (a) by program instruction or otherwise.
(c) Rule of Construction.--Nothing in the provisions of or
amendments made by this section shall be construed as
affecting the application of an accreditation requirement for
pharmacies to qualify for bidding in a competitive
acquisition area under section 1847 of the Social Security
Act (42 U.S.C. 1395w-3).
SEC. 3110. PART B SPECIAL ENROLLMENT PERIOD FOR DISABLED
TRICARE BENEFICIARIES.
(a) In General.--
(1) In general.--Section 1837 of the Social Security Act
(42 U.S.C. 1395p) is amended by adding at the end the
following new subsection:
``(l)(1) In the case of any individual who is a covered
beneficiary (as defined in section 1072(5) of title 10,
United States Code) at the time the individual is entitled to
part A under section 226(b) or section 226A and who is
eligible to enroll but who has elected not to enroll (or to
be deemed enrolled) during the individual's initial
enrollment period, there shall be a special enrollment period
described in paragraph (2).
``(2) The special enrollment period described in this
paragraph, with respect to an individual, is the 12-month
period beginning on the day after the last day of the initial
enrollment period of the individual or, if later, the 12-
month period beginning with the month the individual is
notified of enrollment under this section.
``(3) In the case of an individual who enrolls during the
special enrollment period provided under paragraph (1), the
coverage period under this part shall begin on the first day
of the month in which the individual enrolls, or, at the
option of the individual, the first month after the end of
the individual's initial enrollment period.
``(4) An individual may only enroll during the special
enrollment period provided under paragraph (1) one time
during the individual's lifetime.
``(5) The Secretary shall ensure that the materials
relating to coverage under this part that are provided to an
individual described in paragraph (1) prior to the
individual's initial enrollment period contain information
concerning the impact of not enrolling under this part,
including the impact on health care benefits under the
TRICARE program under chapter 55 of title 10, United States
Code.
``(6) The Secretary of Defense shall collaborate with the
Secretary of Health and Human Services and the Commissioner
of Social Security to provide for the accurate identification
of individuals described in paragraph (1). The Secretary of
Defense shall provide such individuals with notification with
respect to this subsection. The Secretary of Defense shall
collaborate with the Secretary of Health and Human Services
and the Commissioner of Social Security to ensure appropriate
follow up pursuant to any notification provided under the
preceding sentence.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to elections made with respect to initial
enrollment periods that end after the date of the enactment
of this Act.
[[Page H1999]]
(b) Waiver of Increase of Premium.--Section 1839(b) of the
Social Security Act (42 U.S.C. 1395r(b)) is amended by
striking ``section 1837(i)(4)'' and inserting ``subsection
(i)(4) or (l) of section 1837''.
SEC. 3111. PAYMENT FOR BONE DENSITY TESTS.
(a) Payment.--
(1) In general.--Section 1848 of the Social Security Act
(42 U.S.C. 1395w-4) is amended--
(A) in subsection (b)--
(i) in paragraph (4)(B), by inserting ``, and for 2010 and
2011, dual-energy x-ray absorptiometry services (as described
in paragraph (6))'' before the period at the end; and
(ii) by adding at the end the following new paragraph:
``(6) Treatment of bone mass scans.--For dual-energy x-ray
absorptiometry services (identified in 2006 by HCPCS codes
76075 and 76077 (and any succeeding codes)) furnished during
2010 and 2011, instead of the payment amount that would
otherwise be determined under this section for such years,
the payment amount shall be equal to 70 percent of the
product of--
``(A) the relative value for the service (as determined in
subsection (c)(2)) for 2006;
``(B) the conversion factor (established under subsection
(d)) for 2006; and
``(C) the geographic adjustment factor (established under
subsection (e)(2)) for the service for the fee schedule area
for 2010 and 2011, respectively.''; and
(B) in subsection (c)(2)(B)(iv)--
(i) in subclause (II), by striking ``and'' at the end;
(ii) in subclause (III), by striking the period at the end
and inserting ``; and''; and
(iii) by adding at the end the following new subclause:
``(IV) subsection (b)(6) shall not be taken into account in
applying clause (ii)(II) for 2010 or 2011.''.
(2) Implementation.--Notwithstanding any other provision of
law, the Secretary may implement the amendments made by
paragraph (1) by program instruction or otherwise.
(b) Study and Report by the Institute of Medicine.--
(1) In general.--The Secretary of Health and Human Services
is authorized to enter into an agreement with the Institute
of Medicine of the National Academies to conduct a study on
the ramifications of Medicare payment reductions for dual-
energy x-ray absorptiometry (as described in section
1848(b)(6) of the Social Security Act, as added by subsection
(a)(1)) during 2007, 2008, and 2009 on beneficiary access to
bone mass density tests.
(2) Report.--An agreement entered into under paragraph (1)
shall provide for the Institute of Medicine to submit to the
Secretary and to Congress a report containing the results of
the study conducted under such paragraph.
SEC. 3112. REVISION TO THE MEDICARE IMPROVEMENT FUND.
Section 1898(b)(1)(A) of the Social Security Act (42 U.S.C.
1395iii) is amended by striking ``$22,290,000,000'' and
inserting ``$0''.
SEC. 3113. TREATMENT OF CERTAIN COMPLEX DIAGNOSTIC LABORATORY
TESTS.
(a) Demonstration Project.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
conduct a demonstration project under part B title XVIII of
the Social Security Act under which separate payments are
made under such part for complex diagnostic laboratory tests
provided to individuals under such part. Under the
demonstration project, the Secretary shall establish
appropriate payment rates for such tests.
(2) Covered complex diagnostic laboratory test defined.--In
this section, the term ``complex diagnostic laboratory test''
means a diagnostic laboratory test--
(A) that is an analysis of gene protein expression,
topographic genotyping, or a cancer chemotherapy sensitivity
assay;
(B) that is determined by the Secretary to be a laboratory
test for which there is not an alternative test having
equivalent performance characteristics;
(C) which is billed using a Health Care Procedure Coding
System (HCPCS) code other than a not otherwise classified
code under such Coding System;
(D) which is approved or cleared by the Food and Drug
Administration or is covered under title XVIII of the Social
Security Act; and
(E) is described in section 1861(s)(3) of the Social
Security Act (42 U.S.C. 1395x(s)(3)).
(3) Separate payment defined.--In this section, the term
``separate payment'' means direct payment to a laboratory
(including a hospital-based or independent laboratory) that
performs a complex diagnostic laboratory test with respect to
a specimen collected from an individual during a period in
which the individual is a patient of a hospital if the test
is performed after such period of hospitalization and if
separate payment would not otherwise be made under title
XVIII of the Social Security Act by reason of sections
1862(a)(14) and 1866(a)(1)(H)(i) of the such Act (42 U.S.C.
1395y(a)(14); 42 U.S.C. 1395cc(a)(1)(H)(i)).
(b) Duration.--Subject to subsection (c)(2), the Secretary
shall conduct the demonstration project under this section
for the 2-year period beginning on July 1, 2011.
(c) Payments and Limitation.--Payments under the
demonstration project under this section shall--
(1) be made from the Federal Supplemental Medical Insurance
Trust Fund under section 1841 of the Social Security Act (42
U.S.C. 1395t); and
(2) may not exceed $100,000,000.
(d) Report.--Not later than 2 years after the completion of
the demonstration project under this section, the Secretary
shall submit to Congress a report on the project. Such report
shall include--
(1) an assessment of the impact of the demonstration
project on access to care, quality of care, health outcomes,
and expenditures under title XVIII of the Social Security Act
(including any savings under such title); and
(2) such recommendations as the Secretary determines
appropriate.
(e) Implementation Funding.--For purposes of administering
this section (including preparing and submitting the report
under subsection (d)), the Secretary shall provide for the
transfer, from the Federal Supplemental Medical Insurance
Trust Fund under section 1841 of the Social Security Act (42
U.S.C. 1395t), to the Centers for Medicare & Medicaid
Services Program Management Account, of $5,000,000. Amounts
transferred under the preceding sentence shall remain
available until expended.
SEC. 3114. IMPROVED ACCESS FOR CERTIFIED NURSE-MIDWIFE
SERVICES.
Section 1833(a)(1)(K) of the Social Security Act (42 U.S.C.
1395l(a)(1)(K)) is amended by inserting ``(or 100 percent for
services furnished on or after January 1, 2011)'' after
``1992, 65 percent''.
PART II--RURAL PROTECTIONS
SEC. 3121. EXTENSION OF OUTPATIENT HOLD HARMLESS PROVISION.
(a) In General.--Section 1833(t)(7)(D)(i) of the Social
Security Act (42 U.S.C. 1395l(t)(7)(D)(i)) is amended--
(1) in subclause (II)--
(A) in the first sentence, by striking ``2010''and
inserting ``2011''; and
(B) in the second sentence, by striking ``or 2009'' and
inserting ``, 2009, or 2010''; and
(2) in subclause (III), by striking ``January 1, 2010'' and
inserting ``January 1, 2011''.
(b) Permitting All Sole Community Hospitals To Be Eligible
for Hold Harmless.--Section 1833(t)(7)(D)(i)(III) of the
Social Security Act (42 U.S.C. 1395l(t)(7)(D)(i)(III)) is
amended by adding at the end the following new sentence: ``In
the case of covered OPD services furnished on or after
January 1, 2010, and before January 1, 2011, the preceding
sentence shall be applied without regard to the 100-bed
limitation.''.
SEC. 3122. EXTENSION OF MEDICARE REASONABLE COSTS PAYMENTS
FOR CERTAIN CLINICAL DIAGNOSTIC LABORATORY
TESTS FURNISHED TO HOSPITAL PATIENTS IN CERTAIN
RURAL AREAS.
Section 416(b) of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (42 U.S.C. 1395l-
4), as amended by section 105 of division B of the Tax Relief
and Health Care Act of 2006 (42 U.S.C. 1395l note) and
section 107 of the Medicare, Medicaid, and SCHIP Extension
Act of 2007 (42 U.S.C. 1395l note), is amended by inserting
``or during the 1-year period beginning on July 1, 2010''
before the period at the end.
SEC. 3123. EXTENSION OF THE RURAL COMMUNITY HOSPITAL
DEMONSTRATION PROGRAM.
(a) One-year Extension.--Section 410A of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003
(Public Law 108-173; 117 Stat. 2272) is amended by adding at
the end the following new subsection:
``(g) One-Year Extension of Demonstration Program.--
``(1) In general.--Subject to the succeeding provisions of
this subsection, the Secretary shall conduct the
demonstration program under this section for an additional 1-
year period (in this section referred to as the `1-year
extension period') that begins on the date immediately
following the last day of the initial 5-year period under
subsection (a)(5).
``(2) Expansion of demonstration states.--Notwithstanding
subsection (a)(2), during the 1-year extension period, the
Secretary shall expand the number of States with low
population densities determined by the Secretary under such
subsection to 20. In determining which States to include in
such expansion, the Secretary shall use the same criteria and
data that the Secretary used to determine the States under
such subsection for purposes of the initial 5-year period.
``(3) Increase in maximum number of hospitals participating
in the demonstration program.--Notwithstanding subsection
(a)(4), during the 1-year extension period, not more than 30
rural community hospitals may participate in the
demonstration program under this section.
``(4) No affect on hospitals in demonstration program on
date of enactment.--In the case of a rural community hospital
that is participating in the demonstration program under this
section as of the last day of the initial 5-year period, the
Secretary shall provide for the continued participation of
such rural community hospital in the demonstration program
during the 1-year extension period unless the rural community
hospital makes an election, in such form and manner as the
Secretary may specify, to discontinue such participation.''.
(b) Conforming Amendments.--Subsection (a)(5) of section
410A of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (Public Law 108-173; 117 Stat.
2272) is amended by inserting ``(in this section referred to
as the `initial 5-year period') and, as provided in
subsection (g), for the 1-year extension period'' after ``5-
year period''.
(c) Technical Amendments.--
(1) Subsection (b) of section 410A of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003
(Public Law 108-173; 117 Stat. 2272) is amended--
(A) in paragraph (1)(B)(ii), by striking ``2)'' and
inserting ``2))''; and
(B) in paragraph (2), by inserting ``cost'' before
``reporting period'' the first place such term appears in
each of subparagraphs (A) and (B).
(2) Subsection (f)(1) of section 410A of the Medicare
Prescription Drug, Improvement, and
[[Page H2000]]
Modernization Act of 2003 (Public Law 108-173; 117 Stat.
2272) is amended--
(A) in subparagraph (A)(ii), by striking ``paragraph (2)''
and inserting ``subparagraph (B)''; and
(B) in subparagraph (B), by striking ``paragraph (1)(B)''
and inserting ``subparagraph (A)(ii)''.
SEC. 3124. EXTENSION OF THE MEDICARE-DEPENDENT HOSPITAL (MDH)
PROGRAM.
(a) Extension of Payment Methodology.--Section
1886(d)(5)(G) of the Social Security Act (42 U.S.C.
1395ww(d)(5)(G)) is amended--
(1) in clause (i), by striking ``October 1, 2011'' and
inserting ``October 1, 2012''; and
(2) in clause (ii)(II), by striking ``October 1, 2011'' and
inserting ``October 1, 2012''.
(b) Conforming Amendments.--
(1) Extension of target amount.--Section 1886(b)(3)(D) of
the Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is
amended--
(A) in the matter preceding clause (i), by striking
``October 1, 2011'' and inserting ``October 1, 2012''; and
(B) in clause (iv), by striking ``through fiscal year
2011'' and inserting ``through fiscal year 2012''.
(2) Permitting hospitals to decline reclassification.--
Section 13501(e)(2) of the Omnibus Budget Reconciliation Act
of 1993 (42 U.S.C. 1395ww note) is amended by striking
``through fiscal year 2011'' and inserting ``through fiscal
year 2012''.
SEC. 3125. TEMPORARY IMPROVEMENTS TO THE MEDICARE INPATIENT
HOSPITAL PAYMENT ADJUSTMENT FOR LOW-VOLUME
HOSPITALS.
Section 1886(d)(12) of the Social Security Act (42 U.S.C.
1395ww(d)(12)) is amended--
(1) in subparagraph (A), by inserting ``or (D)'' after
``subparagraph (B)'';
(2) in subparagraph (B), in the matter preceding clause
(i), by striking ``The Secretary'' and inserting ``For
discharges occurring in fiscal years 2005 through 2010 and
for discharges occurring in fiscal year 2013 and subsequent
fiscal years, the Secretary'';
(3) in subparagraph (C)(i)--
(A) by inserting ``(or, with respect to fiscal years 2011
and 2012, 15 road miles)'' after ``25 road miles''; and
(B) by inserting ``(or, with respect to fiscal years 2011
and 2012, 1,500 discharges of individuals entitled to, or
enrolled for, benefits under part A)'' after ``800
discharges''; and
(4) by adding at the end the following new subparagraph:
``(D) Temporary applicable percentage increase.--For
discharges occurring in fiscal years 2011 and 2012, the
Secretary shall determine an applicable percentage increase
for purposes of subparagraph (A) using a continuous linear
sliding scale ranging from 25 percent for low-volume
hospitals with 200 or fewer discharges of individuals
entitled to, or enrolled for, benefits under part A in the
fiscal year to 0 percent for low-volume hospitals with
greater than 1,500 discharges of such individuals in the
fiscal year.''.
SEC. 3126. IMPROVEMENTS TO THE DEMONSTRATION PROJECT ON
COMMUNITY HEALTH INTEGRATION MODELS IN CERTAIN
RURAL COUNTIES.
(a) Removal of Limitation on Number of Eligible Counties
Selected.--Subsection (d)(3) of section 123 of the Medicare
Improvements for Patients and Providers Act of 2008 (42
U.S.C. 1395i-4 note) is amended by striking ``not more than
6''.
(b) Removal of References to Rural Health Clinic Services
and Inclusion of Physicians' Services in Scope of
Demonstration Project.--Such section 123 is amended--
(1) in subsection (d)(4)(B)(i)(3), by striking subclause
(III); and
(2) in subsection (j)--
(A) in paragraph (8), by striking subparagraph (B) and
inserting the following:
``(B) Physicians' services (as defined in section 1861(q)
of the Social Security Act (42 U.S.C. 1395x(q)).'';
(B) by striking paragraph (9); and
(C) by redesignating paragraph (10) as paragraph (9).
SEC. 3127. MEDPAC STUDY ON ADEQUACY OF MEDICARE PAYMENTS FOR
HEALTH CARE PROVIDERS SERVING IN RURAL AREAS.
(a) Study.--The Medicare Payment Advisory Commission shall
conduct a study on the adequacy of payments for items and
services furnished by providers of services and suppliers in
rural areas under the Medicare program under title XVIII of
the Social Security Act (42 U.S.C. 1395 et seq.). Such study
shall include an analysis of--
(1) any adjustments in payments to providers of services
and suppliers that furnish items and services in rural areas;
(2) access by Medicare beneficiaries to items and services
in rural areas;
(3) the adequacy of payments to providers of services and
suppliers that furnish items and services in rural areas; and
(4) the quality of care furnished in rural areas.
(b) Report.--Not later than January 1, 2011, the Medicare
Payment Advisory Commission shall submit to Congress a report
containing the results of the study conducted under
subsection (a). Such report shall include recommendations on
appropriate modifications to any adjustments in payments to
providers of services and suppliers that furnish items and
services in rural areas, together with recommendations for
such legislation and administrative action as the Medicare
Payment Advisory Commission determines appropriate.
SEC. 3128. TECHNICAL CORRECTION RELATED TO CRITICAL ACCESS
HOSPITAL SERVICES.
(a) In General.--Subsections (g)(2)(A) and (l)(8) of
section 1834 of the Social Security Act (42 U.S.C. 1395m) are
each amended by inserting ``101 percent of'' before ``the
reasonable costs''.
(b) Effective Date.--The amendments made by subsection (a)
shall take effect as if included in the enactment of section
405(a) of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (Public Law 108-173; 117 Stat.
2266).
SEC. 3129. EXTENSION OF AND REVISIONS TO MEDICARE RURAL
HOSPITAL FLEXIBILITY PROGRAM.
(a) Authorization.--Section 1820(j) of the Social Security
Act (42 U.S.C. 1395i-4(j)) is amended--
(1) by striking ``2010, and for'' and inserting ``2010,
for''; and
(2) by inserting ``and for making grants to all States
under subsection (g), such sums as may be necessary in each
of fiscal years 2011 and 2012, to remain available until
expended'' before the period at the end.
(b) Use of Funds.--Section 1820(g)(3) of the Social
Security Act (42 U.S.C. 1395i-4(g)(3)) is amended--
(1) in subparagraph (A), by inserting ``and to assist such
hospitals in participating in delivery system reforms under
the provisions of and amendments made by the Patient
Protection and Affordable Care Act, such as value-based
purchasing programs, accountable care organizations under
section 1899, the National pilot program on payment bundling
under section 1866D, and other delivery system reform
programs determined appropriate by the Secretary'' before the
period at the end; and
(2) in subparagraph (E)--
(A) by striking ``, and to offset'' and inserting ``, to
offset''; and
(B) by inserting ``and to participate in delivery system
reforms under the provisions of and amendments made by the
Patient Protection and Affordable Care Act, such as value-
based purchasing programs, accountable care organizations
under section 1899, the National pilot program on payment
bundling under section 1866D, and other delivery system
reform programs determined appropriate by the Secretary''
before the period at the end.
(c) Effective Date.--The amendments made by this section
shall apply to grants made on or after January 1, 2010.
PART III--IMPROVING PAYMENT ACCURACY
SEC. 3131. PAYMENT ADJUSTMENTS FOR HOME HEALTH CARE.
(a) Rebasing Home Health Prospective Payment Amount.--
(1) In general.--Section 1895(b)(3)(A) of the Social
Security Act (42 U.S.C. 1395fff(b)(3)(A)) is amended--
(A) in clause (i)(III), by striking ``For periods'' and
inserting ``Subject to clause (iii), for periods''; and
(B) by adding at the end the following new clause:
``(iii) Adjustment for 2013 and subsequent years.--
``(I) In general.--Subject to subclause (II), for 2013 and
subsequent years, the amount (or amounts) that would
otherwise be applicable under clause (i)(III) shall be
adjusted by a percentage determined appropriate by the
Secretary to reflect such factors as changes in the number of
visits in an episode, the mix of services in an episode, the
level of intensity of services in an episode, the average
cost of providing care per episode, and other factors that
the Secretary considers to be relevant. In conducting the
analysis under the preceding sentence, the Secretary may
consider differences between hospital-based and freestanding
agencies, between for-profit and nonprofit agencies, and
between the resource costs of urban and rural agencies. Such
adjustment shall be made before the update under subparagraph
(B) is applied for the year.
``(II) Transition.--The Secretary shall provide for a 4-
year phase-in (in equal increments) of the adjustment under
subclause (I), with such adjustment being fully implemented
for 2016. During each year of such phase-in, the amount of
any adjustment under subclause (I) for the year may not
exceed 3.5 percent of the amount (or amounts) applicable
under clause (i)(III) as of the date of enactment of the
Patient Protection and Affordable Care Act.''.
(2) MedPAC study and report.--
(A) Study.--The Medicare Payment Advisory Commission shall
conduct a study on the implementation of the amendments made
by paragraph (1). Such study shall include an analysis of the
impact of such amendments on--
(i) access to care;
(ii) quality outcomes;
(iii) the number of home health agencies; and
(iv) rural agencies, urban agencies, for-profit agencies,
and nonprofit agencies.
(B) Report.--Not later than January 1, 2015, the Medicare
Payment Advisory Commission shall submit to Congress a report
on the study conducted under subparagraph (A), together with
recommendations for such legislation and administrative
action as the Commission determines appropriate.
(b) Program-specific Outlier Cap.--Section 1895(b) of the
Social Security Act (42 U.S.C. 1395fff(b)) is amended--
(1) in paragraph (3)(C), by striking ``the aggregate'' and
all that follows through the period at the end and inserting
``5 percent of the total payments estimated to be made based
on the prospective payment system under this subsection for
the period.''; and
(2) in paragraph (5)--
(A) by striking ``Outliers.--The Secretary'' and inserting
the following: ``Outliers.--
``(A) In general.--Subject to subparagraph (B), the
Secretary'';
(B) in subparagraph (A), as added by subparagraph (A), by
striking ``5 percent'' and inserting ``2.5 percent''; and
[[Page H2001]]
(C) by adding at the end the following new subparagraph:
``(B) Program specific outlier cap.--The estimated total
amount of additional payments or payment adjustments made
under subparagraph (A) with respect to a home health agency
for a year (beginning with 2011) may not exceed an amount
equal to 10 percent of the estimated total amount of payments
made under this section (without regard to this paragraph)
with respect to the home health agency for the year.''.
(c) Application of the Medicare Rural Home Health Add-on
Policy.--Section 421 of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (Public Law 108-
173; 117 Stat. 2283), as amended by section 5201(b) of the
Deficit Reduction Act of 2005 (Public Law 109-171; 120 Stat.
46), is amended--
(1) in the section heading, by striking ``ONE-YEAR'' and
inserting ``TEMPORARY''; and
(2) in subsection (a)--
(A) by striking ``, and episodes'' and inserting ``,
episodes'';
(B) by inserting ``and episodes and visits ending on or
after April 1, 2010, and before January 1, 2016,'' after
``January 1, 2007,''; and
(C) by inserting ``(or, in the case of episodes and visits
ending on or after April 1, 2010, and before January 1, 2016,
3 percent)'' before the period at the end.
(d) Study and Report on the Development of Home Health
Payment Reforms in Order To Ensure Access to Care and Quality
Services.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
conduct a study to evaluate the costs and quality of care
among efficient home health agencies relative to other such
agencies in providing ongoing access to care and in treating
Medicare beneficiaries with varying severity levels of
illness. Such study shall include an analysis of the
following:
(A) Methods to revise the home health prospective payment
system under section 1895 of the Social Security Act (42
U.S.C. 1395fff) to more accurately account for the costs
related to patient severity of illness or to improving
beneficiary access to care, including--
(i) payment adjustments for services that may be under- or
over-valued;
(ii) necessary changes to reflect the resource use relative
to providing home health services to low-income Medicare
beneficiaries or Medicare beneficiaries living in medically
underserved areas;
(iii) ways the outlier payment may be improved to more
accurately reflect the cost of treating Medicare
beneficiaries with high severity levels of illness;
(iv) the role of quality of care incentives and penalties
in driving provider and patient behavior;
(v) improvements in the application of a wage index; and
(vi) other areas determined appropriate by the Secretary.
(B) The validity and reliability of responses on the OASIS
instrument with particular emphasis on questions that relate
to higher payment under the home health prospective payment
system and higher outcome scores under Home Care Compare.
(C) Additional research or payment revisions under the home
health prospective payment system that may be necessary to
set the payment rates for home health services based on costs
of high-quality and efficient home health agencies or to
improve Medicare beneficiary access to care.
(D) A timetable for implementation of any appropriate
changes based on the analysis of the matters described in
subparagraphs (A), (B), and (C).
(E) Other areas determined appropriate by the Secretary.
(2) Considerations.--In conducting the study under
paragraph (1), the Secretary shall consider whether certain
factors should be used to measure patient severity of illness
and access to care, such as--
(A) population density and relative patient access to care;
(B) variations in service costs for providing care to
individuals who are dually eligible under the Medicare and
Medicaid programs;
(C) the presence of severe or chronic diseases, as
evidenced by multiple, discontinuous home health episodes;
(D) poverty status, as evidenced by the receipt of
Supplemental Security Income under title XVI of the Social
Security Act;
(E) the absence of caregivers;
(F) language barriers;
(G) atypical transportation costs;
(H) security costs; and
(I) other factors determined appropriate by the Secretary.
(3) Report.--Not later than March 1, 2011, the Secretary
shall submit to Congress a report on the study conducted
under paragraph (1), together with recommendations for such
legislation and administrative action as the Secretary
determines appropriate.
(4) Consultations.--In conducting the study under paragraph
(1) and preparing the report under paragraph (3), the
Secretary shall consult with--
(A) stakeholders representing home health agencies;
(B) groups representing Medicare beneficiaries;
(C) the Medicare Payment Advisory Commission;
(D) the Inspector General of the Department of Health and
Human Services; and
(E) the Comptroller General of the United States.
SEC. 3132. HOSPICE REFORM.
(a) Hospice Care Payment Reforms.--
(1) In general.--Section 1814(i) of the Social Security Act
(42 U.S.C. 1395f(i)), as amended by section 3004(c), is
amended--
(A) by redesignating paragraph (6) as paragraph (7); and
(B) by inserting after paragraph (5) the following new
paragraph:
``(6)(A) The Secretary shall collect additional data and
information as the Secretary determines appropriate to revise
payments for hospice care under this subsection pursuant to
subparagraph (D) and for other purposes as determined
appropriate by the Secretary. The Secretary shall begin to
collect such data by not later than January 1, 2011.
``(B) The additional data and information to be collected
under subparagraph (A) may include data and information on--
``(i) charges and payments;
``(ii) the number of days of hospice care which are
attributable to individuals who are entitled to, or enrolled
for, benefits under part A; and
``(iii) with respect to each type of service included in
hospice care--
``(I) the number of days of hospice care attributable to
the type of service;
``(II) the cost of the type of service; and
``(III) the amount of payment for the type of service;
``(iv) charitable contributions and other revenue of the
hospice program;
``(v) the number of hospice visits;
``(vi) the type of practitioner providing the visit; and
``(vii) the length of the visit and other basic information
with respect to the visit.
``(C) The Secretary may collect the additional data and
information under subparagraph (A) on cost reports, claims,
or other mechanisms as the Secretary determines to be
appropriate.
``(D)(i) Notwithstanding the preceding paragraphs of this
subsection, not earlier than October 1, 2013, the Secretary
shall, by regulation, implement revisions to the methodology
for determining the payment rates for routine home care and
other services included in hospice care under this part, as
the Secretary determines to be appropriate. Such revisions
may be based on an analysis of data and information collected
under subparagraph (A). Such revisions may include
adjustments to per diem payments that reflect changes in
resource intensity in providing such care and services during
the course of the entire episode of hospice care.
``(ii) Revisions in payment implemented pursuant to clause
(i) shall result in the same estimated amount of aggregate
expenditures under this title for hospice care furnished in
the fiscal year in which such revisions in payment are
implemented as would have been made under this title for such
care in such fiscal year if such revisions had not been
implemented.
``(E) The Secretary shall consult with hospice programs and
the Medicare Payment Advisory Commission regarding the
additional data and information to be collected under
subparagraph (A) and the payment revisions under subparagraph
(D).''.
(2) Conforming amendments.--Section 1814(i)(1)(C) of the
Social Security Act (42 U.S.C. 1395f(i)(1)(C)) is amended--
(A) in clause (ii)--
(i) in the matter preceding subclause (I), by inserting
``(before the first fiscal year in which the payment
revisions described in paragraph (6)(D) are implemented)''
after ``subsequent fiscal year''; and
(ii) in subclause (VII), by inserting ``(before the first
fiscal year in which the payment revisions described in
paragraph (6)(D) are implemented), subject to clause (iv),''
after ``subsequent fiscal year''; and
(B) by adding at the end the following new clause:
``(iii) With respect to routine home care and other
services included in hospice care furnished during fiscal
years subsequent to the first fiscal year in which payment
revisions described in paragraph (6)(D) are implemented, the
payment rates for such care and services shall be the payment
rates in effect under this clause during the preceding fiscal
year increased by, subject to clause (iv), the market basket
percentage increase (as defined in section
1886(b)(3)(B)(iii)) for the fiscal year.''.
(b) Adoption of MedPAC Hospice Program Eligibility
Recertification Recommendations.--Section 1814(a)(7) of the
Social Security Act (42 U.S.C. 1395f(a)(7)) is amended--
(1) in subparagraph (B), by striking ``and'' at the end;
and
(2) by adding at the end the following new subparagraph:
``(D) on and after January 1, 2011--
``(i) a hospice physician or nurse practitioner has a face-
to-face encounter with the individual to determine continued
eligibility of the individual for hospice care prior to the
180th-day recertification and each subsequent recertification
under subparagraph (A)(ii) and attests that such visit took
place (in accordance with procedures established by the
Secretary); and
``(ii) in the case of hospice care provided an individual
for more than 180 days by a hospice program for which the
number of such cases for such program comprises more than a
percent (specified by the Secretary) of the total number of
such cases for all programs under this title, the hospice
care provided to such individual is medically reviewed (in
accordance with procedures established by the Secretary);
and''.
SEC. 3133. IMPROVEMENT TO MEDICARE DISPROPORTIONATE SHARE
HOSPITAL (DSH) PAYMENTS.
Section 1886 of the Social Security Act (42 U.S.C. 1395ww),
as amended by sections 3001, 3008, and 3025, is amended--
(1) in subsection (d)(5)(F)(i), by striking ``For'' and
inserting ``Subject to subsection (r), for''; and
(2) by adding at the end the following new subsection:
``(r) Adjustments to Medicare DSH Payments.--
[[Page H2002]]
``(1) Empirically justified dsh payments.--For fiscal year
2015 and each subsequent fiscal year, instead of the amount
of disproportionate share hospital payment that would
otherwise be made under subsection (d)(5)(F) to a subsection
(d) hospital for the fiscal year, the Secretary shall pay to
the subsection (d) hospital 25 percent of such amount (which
represents the empirically justified amount for such payment,
as determined by the Medicare Payment Advisory Commission in
its March 2007 Report to the Congress).
``(2) Additional payment.--In addition to the payment made
to a subsection (d) hospital under paragraph (1), for fiscal
year 2015 and each subsequent fiscal year, the Secretary
shall pay to such subsection (d) hospitals an additional
amount equal to the product of the following factors:
``(A) Factor one.--A factor equal to the difference
between--
``(i) the aggregate amount of payments that would be made
to subsection (d) hospitals under subsection (d)(5)(F) if
this subsection did not apply for such fiscal year (as
estimated by the Secretary); and
``(ii) the aggregate amount of payments that are made to
subsection (d) hospitals under paragraph (1) for such fiscal
year (as so estimated).
``(B) Factor two.--
``(i) Fiscal years 2015, 2016, and 2017.--For each of
fiscal years 2015, 2016, and 2017, a factor equal to 1 minus
the percent change (divided by 100) in the percent of
individuals under the age of 65 who are uninsured, as
determined by comparing the percent of such individuals--
``(I) who are uninsured in 2012, the last year before
coverage expansion under the Patient Protection and
Affordable Care Act (as calculated by the Secretary based on
the most recent estimates available from the Director of the
Congressional Budget Office before a vote in either House on
such Act that, if determined in the affirmative, would clear
such Act for enrollment); and
``(II) who are uninsured in the most recent period for
which data is available (as so calculated).
``(ii) 2018 and subsequent years.--For fiscal year 2018 and
each subsequent fiscal year, a factor equal to 1 minus the
percent change (divided by 100) in the percent of individuals
who are uninsured, as determined by comparing the percent of
individuals--
``(I) who are uninsured in 2012 (as estimated by the
Secretary, based on data from the Census Bureau or other
sources the Secretary determines appropriate, and certified
by the Chief Actuary of the Centers for Medicare & Medicaid
Services); and
``(II) who are uninsured in the most recent period for
which data is available (as so estimated and certified).
``(C) Factor three.--A factor equal to the percent, for
each subsection (d) hospital, that represents the quotient
of--
``(i) the amount of uncompensated care for such hospital
for a period selected by the Secretary (as estimated by the
Secretary, based on appropriate data (including, in the case
where the Secretary determines that alternative data is
available which is a better proxy for the costs of subsection
(d) hospitals for treating the uninsured, the use of such
alternative data)); and
``(ii) the aggregate amount of uncompensated care for all
subsection (d) hospitals that receive a payment under this
subsection for such period (as so estimated, based on such
data).
``(3) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of the following:
``(A) Any estimate of the Secretary for purposes of
determining the factors described in paragraph (2).
``(B) Any period selected by the Secretary for such
purposes.''.
SEC. 3134. MISVALUED CODES UNDER THE PHYSICIAN FEE SCHEDULE.
(a) In General.--Section 1848(c)(2) of the Social Security
Act (42 U.S.C. 1395w-4(c)(2)) is amended by adding at the end
the following new subparagraphs:
``(K) Potentially misvalued codes.--
``(i) In general.--The Secretary shall--
``(I) periodically identify services as being potentially
misvalued using criteria specified in clause (ii); and
``(II) review and make appropriate adjustments to the
relative values established under this paragraph for services
identified as being potentially misvalued under subclause
(I).
``(ii) Identification of potentially misvalued codes.--For
purposes of identifying potentially misvalued services
pursuant to clause (i)(I), the Secretary shall examine (as
the Secretary determines to be appropriate) codes (and
families of codes as appropriate) for which there has been
the fastest growth; codes (and families of codes as
appropriate) that have experienced substantial changes in
practice expenses; codes for new technologies or services
within an appropriate period (such as 3 years) after the
relative values are initially established for such codes;
multiple codes that are frequently billed in conjunction with
furnishing a single service; codes with low relative values,
particularly those that are often billed multiple times for a
single treatment; codes which have not been subject to review
since the implementation of the RBRVS (the so-called
`Harvard-valued codes'); and such other codes determined to
be appropriate by the Secretary.
``(iii) Review and adjustments.--
``(I) The Secretary may use existing processes to receive
recommendations on the review and appropriate adjustment of
potentially misvalued services described in clause (i)(II).
``(II) The Secretary may conduct surveys, other data
collection activities, studies, or other analyses as the
Secretary determines to be appropriate to facilitate the
review and appropriate adjustment described in clause
(i)(II).
``(III) The Secretary may use analytic contractors to
identify and analyze services identified under clause (i)(I),
conduct surveys or collect data, and make recommendations on
the review and appropriate adjustment of services described
in clause (i)(II).
``(IV) The Secretary may coordinate the review and
appropriate adjustment described in clause (i)(II) with the
periodic review described in subparagraph (B).
``(V) As part of the review and adjustment described in
clause (i)(II), including with respect to codes with low
relative values described in clause (ii), the Secretary may
make appropriate coding revisions (including using existing
processes for consideration of coding changes) which may
include consolidation of individual services into bundled
codes for payment under the fee schedule under subsection
(b).
``(VI) The provisions of subparagraph (B)(ii)(II) shall
apply to adjustments to relative value units made pursuant to
this subparagraph in the same manner as such provisions apply
to adjustments under subparagraph (B)(ii)(II).
``(L) Validating relative value units.--
``(i) In general.--The Secretary shall establish a process
to validate relative value units under the fee schedule under
subsection (b).
``(ii) Components and elements of work.--The process
described in clause (i) may include validation of work
elements (such as time, mental effort and professional
judgment, technical skill and physical effort, and stress due
to risk) involved with furnishing a service and may include
validation of the pre-, post-, and intra-service components
of work.
``(iii) Scope of codes.--The validation of work relative
value units shall include a sampling of codes for services
that is the same as the codes listed under subparagraph
(K)(ii).
``(iv) Methods.--The Secretary may conduct the validation
under this subparagraph using methods described in subclauses
(I) through (V) of subparagraph (K)(iii) as the Secretary
determines to be appropriate.
``(v) Adjustments.--The Secretary shall make appropriate
adjustments to the work relative value units under the fee
schedule under subsection (b). The provisions of subparagraph
(B)(ii)(II) shall apply to adjustments to relative value
units made pursuant to this subparagraph in the same manner
as such provisions apply to adjustments under subparagraph
(B)(ii)(II).''.
(b) Implementation.--
(1) Administration.--
(A) Chapter 35 of title 44, United States Code and the
provisions of the Federal Advisory Committee Act (5 U.S.C.
App.) shall not apply to this section or the amendment made
by this section.
(B) Notwithstanding any other provision of law, the
Secretary may implement subparagraphs (K) and (L) of
1848(c)(2) of the Social Security Act, as added by subsection
(a), by program instruction or otherwise.
(C) Section 4505(d) of the Balanced Budget Act of 1997 is
repealed.
(D) Except for provisions related to confidentiality of
information, the provisions of the Federal Acquisition
Regulation shall not apply to this section or the amendment
made by this section.
(2) Focusing cms resources on potentially overvalued
codes.--Section 1868(a) of the Social Security Act (42 U.S.C.
1395ee(a)) is repealed.
SEC. 3135. MODIFICATION OF EQUIPMENT UTILIZATION FACTOR FOR
ADVANCED IMAGING SERVICES.
(a) Adjustment in Practice Expense To Reflect Higher
Presumed Utilization.--Section 1848 of the Social Security
Act (42 U.S.C. 1395w-4) is amended--
(1) in subsection (b)(4)--
(A) in subparagraph (B), by striking ``subparagraph (A)''
and inserting ``this paragraph''; and
(B) by adding at the end the following new subparagraph:
``(C) Adjustment in practice expense to reflect higher
presumed utilization.--Consistent with the methodology for
computing the number of practice expense relative value units
under subsection (c)(2)(C)(ii) with respect to advanced
diagnostic imaging services (as defined in section
1834(e)(1)(B)) furnished on or after January 1, 2010, the
Secretary shall adjust such number of units so it reflects--
``(i) in the case of services furnished on or after January
1, 2010, and before January 1, 2013, a 65 percent (rather
than 50 percent) presumed rate of utilization of imaging
equipment;
``(ii) in the case of services furnished on or after
January 1, 2013, and before January 1, 2014, a 70 percent
(rather than 50 percent) presumed rate of utilization of
imaging equipment; and
``(iii) in the case of services furnished on or after
January 1, 2014, a 75 percent (rather than 50 percent)
presumed rate of utilization of imaging equipment.''; and
(2) in subsection (c)(2)(B)(v), by adding at the end the
following new subclauses:
``(III) Change in presumed utilization level of certain
advanced diagnostic imaging services for 2010 through 2012.--
Effective for fee schedules established beginning with 2010
and ending with 2012, reduced expenditures attributable to
the presumed rate of utilization of imaging equipment of 65
percent under subsection (b)(4)(C)(i) instead of a presumed
rate of utilization of such equipment of 50 percent.
``(IV) Change in presumed utilization level of certain
advanced diagnostic imaging services for 2013.--Effective for
fee schedules established for 2013, reduced expenditures
attributable to the presumed rate of utilization of imaging
equipment of 70 percent under subsection (b)(4)(C)(ii)
instead of a presumed rate of utilization of such equipment
of 50 percent.
[[Page H2003]]
``(V) Change in presumed utilization level of certain
advanced diagnostic imaging services for 2014 and subsequent
years.--Effective for fee schedules established beginning
with 2014, reduced expenditures attributable to the presumed
rate of utilization of imaging equipment of 75 percent under
subsection (b)(4)(C)(iii) instead of a presumed rate of
utilization of such equipment of 50 percent.''.
(b) Adjustment in Technical Component ``discount'' on
Single-session Imaging to Consecutive Body Parts.--Section
1848 of the Social Security Act (42 U.S.C. 1395w-4), as
amended by subsection (a), is amended--
(1) in subsection (b)(4), by adding at the end the
following new subparagraph:
``(D) Adjustment in technical component discount on single-
session imaging involving consecutive body parts.--For
services furnished on or after July 1, 2010, the Secretary
shall increase the reduction in payments attributable to the
multiple procedure payment reduction applicable to the
technical component for imaging under the final rule
published by the Secretary in the Federal Register on
November 21, 2005 (part 405 of title 42, Code of Federal
Regulations) from 25 percent to 50 percent.''; and
(2) in subsection (c)(2)(B)(v), by adding at the end the
following new subclause:
``(VI) Additional reduced payment for multiple imaging
procedures.--Effective for fee schedules established
beginning with 2010 (but not applied for services furnished
prior to July 1, 2010), reduced expenditures attributable to
the increase in the multiple procedure payment reduction from
25 to 50 percent (as described in subsection (b)(4)(D)).''.
(c) Analysis by the Chief Actuary of the Centers for
Medicare & Medicaid Services.--Not later than January 1,
2013, the Chief Actuary of the Centers for Medicare &
Medicaid Services shall make publicly available an analysis
of whether, for the period of 2010 through 2019, the
cumulative expenditure reductions under title XVIII of the
Social Security Act that are attributable to the adjustments
under the amendments made by this section are projected to
exceed $3,000,000,000.
SEC. 3136. REVISION OF PAYMENT FOR POWER-DRIVEN WHEELCHAIRS.
(a) In General.--Section 1834(a)(7)(A) of the Social
Security Act (42 U.S.C. 1395m(a)(7)(A)) is amended--
(1) in clause (i)--
(A) in subclause (II), by inserting ``subclause (III) and''
after ``Subject to''; and
(B) by adding at the end the following new subclause:
``(III) Special rule for power-driven wheelchairs.--For
purposes of payment for power-driven wheelchairs, subclause
(II) shall be applied by substituting `15 percent' and `6
percent' for `10 percent' and `7.5 percent', respectively.'';
and
(2) in clause (iii)--
(A) in the heading, by inserting ``complex,
rehabilitative'' before ``power-driven''; and
(B) by inserting ``complex, rehabilitative'' before
``power-driven''.
(b) Technical Amendment.--Section 1834(a)(7)(C)(ii)(II) of
the Social Security Act (42 U.S.C. 1395m(a)(7)(C)(ii)(II)) is
amended by striking ``(A)(ii) or''.
(c) Effective Date.--
(1) In general.--Subject to paragraph (2), the amendments
made by subsection (a) shall take effect on January 1, 2011,
and shall apply to power-driven wheelchairs furnished on or
after such date.
(2) Application to competitive bidding.--The amendments
made by subsection (a) shall not apply to payment made for
items and services furnished pursuant to contracts entered
into under section 1847 of the Social Security Act (42 U.S.C.
1395w-3) prior to January 1, 2011, pursuant to the
implementation of subsection (a)(1)(B)(i)(I) of such section
1847.
SEC. 3137. HOSPITAL WAGE INDEX IMPROVEMENT.
(a) Extension of Section 508 Hospital Reclassifications.--
(1) In general.--Subsection (a) of section 106 of division
B of the Tax Relief and Health Care Act of 2006 (42 U.S.C.
1395 note), as amended by section 117 of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-
173) and section 124 of the Medicare Improvements for
Patients and Providers Act of 2008 (Public Law 110-275), is
amended by striking ``September 30, 2009'' and inserting
``September 30, 2010''.
(2) Use of particular wage index in fiscal year 2010.--For
purposes of implementation of the amendment made by this
subsection during fiscal year 2010, the Secretary shall use
the hospital wage index that was promulgated by the Secretary
in the Federal Register on August 27, 2009 (74 Fed. Reg.
43754), and any subsequent corrections.
(b) Plan for Reforming the Medicare Hospital Wage Index
System.--
(1) In general.--Not later than December 31, 2011, the
Secretary of Health and Human Services (in this section
referred to as the ``Secretary'') shall submit to Congress a
report that includes a plan to reform the hospital wage index
system under section 1886 of the Social Security Act.
(2) Details.--In developing the plan under paragraph (1),
the Secretary shall take into account the goals for reforming
such system set forth in the Medicare Payment Advisory
Commission June 2007 report entitled ``Report to Congress:
Promoting Greater Efficiency in Medicare'', including
establishing a new hospital compensation index system that--
(A) uses Bureau of Labor Statistics data, or other data or
methodologies, to calculate relative wages for each
geographic area involved;
(B) minimizes wage index adjustments between and within
metropolitan statistical areas and statewide rural areas;
(C) includes methods to minimize the volatility of wage
index adjustments that result from implementation of policy,
while maintaining budget neutrality in applying such
adjustments;
(D) takes into account the effect that implementation of
the system would have on health care providers and on each
region of the country;
(E) addresses issues related to occupational mix, such as
staffing practices and ratios, and any evidence on the effect
on quality of care or patient safety as a result of the
implementation of the system; and
(F) provides for a transition.
(3) Consultation.--In developing the plan under paragraph
(1), the Secretary shall consult with relevant affected
parties.
(c) Use of Particular Criteria for Determining
Reclassifications.--Notwithstanding any other provision of
law, in making decisions on applications for reclassification
of a subsection (d) hospital (as defined in paragraph (1)(B)
of section 1886(d) of the Social Security Act (42 U.S.C.
1395ww(d)) for the purposes described in paragraph (10)(D)(v)
of such section for fiscal year 2011 and each subsequent
fiscal year (until the first fiscal year beginning on or
after the date that is 1 year after the Secretary of Health
and Human Services submits the report to Congress under
subsection (b)), the Geographic Classification Review Board
established under paragraph (10) of such section shall use
the average hourly wage comparison criteria used in making
such decisions as of September 30, 2008. The preceding
sentence shall be effected in a budget neutral manner.
SEC. 3138. TREATMENT OF CERTAIN CANCER HOSPITALS.
Section 1833(t) of the Social Security Act (42 U.S.C.
1395l(t)) is amended by adding at the end the following new
paragraph:
``(18) Authorization of adjustment for cancer hospitals.--
``(A) Study.--The Secretary shall conduct a study to
determine if, under the system under this subsection, costs
incurred by hospitals described in section 1886(d)(1)(B)(v)
with respect to ambulatory payment classification groups
exceed those costs incurred by other hospitals furnishing
services under this subsection (as determined appropriate by
the Secretary). In conducting the study under this
subparagraph, the Secretary shall take into consideration the
cost of drugs and biologicals incurred by such hospitals.
``(B) Authorization of adjustment.--Insofar as the
Secretary determines under subparagraph (A) that costs
incurred by hospitals described in section 1886(d)(1)(B)(v)
exceed those costs incurred by other hospitals furnishing
services under this subsection, the Secretary shall provide
for an appropriate adjustment under paragraph (2)(E) to
reflect those higher costs effective for services furnished
on or after January 1, 2011.''.
SEC. 3139. PAYMENT FOR BIOSIMILAR BIOLOGICAL PRODUCTS.
(a) In General.--Section 1847A of the Social Security Act
(42 U.S.C. 1395w-3a) is amended--
(1) in subsection (b)--
(A) in paragraph (1)--
(i) in subparagraph (A), by striking ``or'' at the end;
(ii) in subparagraph (B), by striking the period at the end
and inserting ``; or''; and
(iii) by adding at the end the following new subparagraph:
``(C) in the case of a biosimilar biological product (as
defined in subsection (c)(6)(H)), the amount determined under
paragraph (8).''; and
(B) by adding at the end the following new paragraph:
``(8) Biosimilar biological product.--The amount specified
in this paragraph for a biosimilar biological product
described in paragraph (1)(C) is the sum of--
``(A) the average sales price as determined using the
methodology described under paragraph (6) applied to a
biosimilar biological product for all National Drug Codes
assigned to such product in the same manner as such paragraph
is applied to drugs described in such paragraph; and
``(B) 6 percent of the amount determined under paragraph
(4) for the reference biological product (as defined in
subsection (c)(6)(I)).''; and
(2) in subsection (c)(6), by adding at the end the
following new subparagraph:
``(H) Biosimilar biological product.--The term `biosimilar
biological product' means a biological product approved under
an abbreviated application for a license of a biological
product that relies in part on data or information in an
application for another biological product licensed under
section 351 of the Public Health Service Act.
``(I) Reference biological product.--The term `reference
biological product' means the biological product licensed
under such section 351 that is referred to in the application
described in subparagraph (H) of the biosimilar biological
product.''.
(b) Effective Date.--The amendments made by subsection (a)
shall apply to payments for biosimilar biological products
beginning with the first day of the second calendar quarter
after enactment of legislation providing for a biosimilar
pathway (as determined by the Secretary).
SEC. 3140. MEDICARE HOSPICE CONCURRENT CARE DEMONSTRATION
PROGRAM.
(a) Establishment.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
establish a Medicare Hospice Concurrent Care demonstration
program at participating hospice programs under which
Medicare beneficiaries are furnished, during the same period,
hospice care and any other items or
[[Page H2004]]
services covered under title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.) from funds otherwise paid under such
title to such hospice programs.
(2) Duration.--The demonstration program under this section
shall be conducted for a 3-year period.
(3) Sites.--The Secretary shall select not more than 15
hospice programs at which the demonstration program under
this section shall be conducted. Such hospice programs shall
be located in urban and rural areas.
(b) Independent Evaluation and Reports.--
(1) Independent evaluation.--The Secretary shall provide
for the conduct of an independent evaluation of the
demonstration program under this section. Such independent
evaluation shall determine whether the demonstration program
has improved patient care, quality of life, and cost-
effectiveness for Medicare beneficiaries participating in the
demonstration program.
(2) Reports.--The Secretary shall submit to Congress a
report containing the results of the evaluation conducted
under paragraph (1), together with such recommendations as
the Secretary determines appropriate.
(c) Budget Neutrality.--With respect to the 3-year period
of the demonstration program under this section, the
Secretary shall ensure that the aggregate expenditures under
title XVIII for such period shall not exceed the aggregate
expenditures that would have been expended under such title
if the demonstration program under this section had not been
implemented.
SEC. 3141. APPLICATION OF BUDGET NEUTRALITY ON A NATIONAL
BASIS IN THE CALCULATION OF THE MEDICARE
HOSPITAL WAGE INDEX FLOOR.
In the case of discharges occurring on or after October 1,
2010, for purposes of applying section 4410 of the Balanced
Budget Act of 1997 (42 U.S.C. 1395ww note) and paragraph
(h)(4) of section 412.64 of title 42, Code of Federal
Regulations, the Secretary of Health and Human Services shall
administer subsection (b) of such section 4410 and paragraph
(e) of such section 412.64 in the same manner as the
Secretary administered such subsection (b) and paragraph (e)
for discharges occurring during fiscal year 2008 (through a
uniform, national adjustment to the area wage index).
SEC. 3142. HHS STUDY ON URBAN MEDICARE-DEPENDENT HOSPITALS.
(a) Study.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
conduct a study on the need for an additional payment for
urban Medicare-dependent hospitals for inpatient hospital
services under section 1886 of the Social Security Act (42
U.S.C. 1395ww). Such study shall include an analysis of--
(A) the Medicare inpatient margins of urban Medicare-
dependent hospitals, as compared to other hospitals which
receive 1 or more additional payments or adjustments under
such section (including those payments or adjustments
described in paragraph (2)(A)); and
(B) whether payments to medicare-dependent, small rural
hospitals under subsection (d)(5)(G) of such section should
be applied to urban Medicare-dependent hospitals.
(2) Urban medicare-dependent hospital defined.--For
purposes of this section, the term ``urban Medicare-dependent
hospital'' means a subsection (d) hospital (as defined in
subsection (d)(1)(B) of such section) that--
(A) does not receive any additional payment or adjustment
under such section, such as payments for indirect medical
education costs under subsection (d)(5)(B) of such section,
disproportionate share payments under subsection (d)(5)(A) of
such section, payments to a rural referral center under
subsection (d)(5)(C) of such section, payments to a critical
access hospital under section 1814(l) of such Act (42 U.S.C.
1395f(l)), payments to a sole community hospital under
subsection (d)(5)(D) of such section 1886, or payments to a
medicare-dependent, small rural hospital under subsection
(d)(5)(G) of such section 1886; and
(B) for which more than 60 percent of its inpatient days or
discharges during 2 of the 3 most recently audited cost
reporting periods for which the Secretary has a settled cost
report were attributable to inpatients entitled to benefits
under part A of title XVIII of such Act.
(b) Report.--Not later than 9 months after the date of
enactment of this Act, the Secretary shall submit to Congress
a report containing the results of the study conducted under
subsection (a), together with recommendations for such
legislation and administrative action as the Secretary
determines appropriate.
SEC. 3143. PROTECTING HOME HEALTH BENEFITS.
Nothing in the provisions of, or amendments made by, this
Act shall result in the reduction of guaranteed home health
benefits under title XVIII of the Social Security Act.
Subtitle C--Provisions Relating to Part C
SEC. 3201. MEDICARE ADVANTAGE PAYMENT.
(a) MA Benchmark Based on Plan's Competitive Bids.--
(1) In general.--Section 1853(j) of the Social Security Act
(42 U.S.C. 1395w-23(j)) is amended--
(A) by striking ``Amounts.--For purposes'' and inserting
``Amounts.--
``(1) In general.--For purposes'';
(B) by redesignating paragraphs (1) and (2) as
subparagraphs (A) and (B), respectively, and indenting the
subparagraphs appropriately;
(C) in subparagraph (A), as redesignated by subparagraph
(B)--
(i) by redesignating subparagraphs (A) and (B) as clauses
(i) and (ii), respectively, and indenting the clauses
appropriately; and
(ii) in clause (i), as redesignated by clause (i), by
striking ``an amount equal to'' and all that follows through
the end and inserting ``an amount equal to--
``(I) for years before 2007, \1/12\ of the annual MA
capitation rate under section 1853(c)(1) for the area for the
year, adjusted as appropriate for the purpose of risk
adjustment;
``(II) for 2007 through 2011, \1/12\ of the applicable
amount determined under subsection (k)(1) for the area for
the year;
``(III) for 2012, the sum of--
``(aa) \2/3\ of the quotient of--
``(AA) the applicable amount determined under subsection
(k)(1) for the area for the year; and
``(BB) 12; and
``(bb) \1/3\ of the MA competitive benchmark amount
(determined under paragraph (2)) for the area for the month;
``(IV) for 2013, the sum of--
``(aa) \1/3\ of the quotient of--
``(AA) the applicable amount determined under subsection
(k)(1) for the area for the year; and
``(BB) 12; and
``(bb) \2/3\ of the MA competitive benchmark amount (as so
determined) for the area for the month;
``(V) for 2014, the MA competitive benchmark amount for the
area for a month in 2013 (as so determined), increased by the
national per capita MA growth percentage, described in
subsection (c)(6) for 2014, but not taking into account any
adjustment under subparagraph (C) of such subsection for a
year before 2004; and
``(VI) for 2015 and each subsequent year, the MA
competitive benchmark amount (as so determined) for the area
for the month; or'';
(iii) in clause (ii), as redesignated by clause (i), by
striking ``subparagraph (A)'' and inserting ``clause (i)'';
(D) by adding at the end the following new paragraphs:
``(2) Computation of ma competitive benchmark amount.--
``(A) In general.--Subject to subparagraph (B) and
paragraph (3), for months in each year (beginning with 2012)
for each MA payment area the Secretary shall compute an MA
competitive benchmark amount equal to the weighted average of
the unadjusted MA statutory non-drug monthly bid amount (as
defined in section 1854(b)(2)(E)) for each MA plan in the
area, with the weight for each plan being equal to the
average number of beneficiaries enrolled under such plan in
the reference month (as defined in section 1858(f)(4), except
that, in applying such definition for purposes of this
paragraph, `to compute the MA competitive benchmark amount
under section 1853(j)(2)' shall be substituted for `to
compute the percentage specified in subparagraph (A) and
other relevant percentages under this part').
``(B) Weighting rules.--
``(i) Single plan rule.--In the case of an MA payment area
in which only a single MA plan is being offered, the weight
under subparagraph (A) shall be equal to 1.
``(ii) Use of simple average among multiple plans if no
plans offered in previous year.--In the case of an MA payment
area in which no MA plan was offered in the previous year and
more than 1 MA plan is offered in the current year, the
Secretary shall use a simple average of the unadjusted MA
statutory non-drug monthly bid amount (as so defined) for
purposes of computing the MA competitive benchmark amount
under subparagraph (A).
``(3) Cap on ma competitive benchmark amount.--In no case
shall the MA competitive benchmark amount for an area for a
month in a year be greater than the applicable amount that
would (but for the application of this subsection) be
determined under subsection (k)(1) for the area for the month
in the year.''; and
(E) in subsection (k)(2)(B)(ii)(III), by striking
``(j)(1)(A)'' and inserting ``(j)(1)(A)(i)''.
(2) Conforming amendments.--
(A) Section 1853(k)(2) of the Social Security Act (42
U.S.C. 1395w-23(k)(2)) is amended--
(i) in subparagraph (A), by striking ``through 2010'' and
inserting ``and subsequent years''; and
(ii) in subparagraph (C)--
(I) in clause (iii), by striking ``and'' at the end;
(II) in clause (iv), by striking the period at the end and
inserting ``; and''; and
(III) by adding at the end the following new clause:
``(v) for 2011 and subsequent years, 0.00.''.
(B) Section 1854(b) of the Social Security Act (42 U.S.C.
1395w-24(b)) is amended--
(i) in paragraph (3)(B)(i), by striking ``1853(j)(1)'' and
inserting ``1853(j)(1)(A)''; and
(ii) in paragraph (4)(B)(i), by striking ``1853(j)(2)'' and
inserting ``1853(j)(1)(B)''.
(C) Section 1858(f) of the Social Security Act (42 U.S.C.
1395w-27(f)) is amended--
(i) in paragraph (1), by striking ``1853(j)(2)'' and
inserting ``1853(j)(1)(B)''; and
(ii) in paragraph (3)(A), by striking ``1853(j)(1)(A)'' and
inserting ``1853(j)(1)(A)(i)''.
(D) Section 1860C-1(d)(1)(A) of the Social Security Act (42
U.S.C. 1395w-29(d)(1)(A)) is amended by striking
``1853(j)(1)(A)'' and inserting ``1853(j)(1)(A)(i)''.
(b) Reduction of National Per Capita Growth Percentage for
2011.--Section 1853(c)(6) of the Social Security Act (42
U.S.C. 1395w-23(c)(6)) is amended--
(1) in clause (v), by striking ``and'' at the end;
(2) in clause (vi)--
(A) by striking ``for a year after 2002'' and inserting
``for 2003 through 2010''; and
(B) by striking the period at the end and inserting a
comma; and
(C) by adding at the end the following new clauses:
``(vii) for 2011, 3 percentage points; and
``(viii) for a year after 2011, 0 percentage points.''.
(c) Enhancement of Beneficiary Rebates.--Section
1854(b)(1)(C)(i) of the Social Security
[[Page H2005]]
Act (42 U.S.C. 1395w-24(b)(1)(C)(i)) is amended by inserting
``(or 100 percent in the case of plan years beginning on or
after January 1, 2014)'' after ``75 percent''.
(d) Bidding Rules.--
(1) Requirements for information submitted.--Section
1854(a)(6)(A) of the Social Security Act (42 U.S.C. 1395w-
24(a)(6)(A)) is amended, in the flush matter following clause
(v), by adding at the end the following sentence:
``Information to be submitted under this paragraph shall be
certified by a qualified member of the American Academy of
Actuaries and shall meet actuarial guidelines and rules
established by the Secretary under subparagraph (B)(v).''.
(2) Establishment of actuarial guidelines.--Section
1854(a)(6)(B) of the Social Security Act (42 U.S.C. 1395w-
24(a)(6)(B)) is amended--
(A) in clause (i), by striking ``(iii) and (iv)'' and
inserting ``(iii), (iv), and (v)''; and
(B) by adding at the end the following new clause:
``(v) Establishment of actuarial guidelines.--
``(I) In general.--In order to establish fair MA
competitive benchmarks under section 1853(j)(1)(A)(i), the
Secretary, acting through the Chief Actuary of the Centers
for Medicare & Medicaid Services (in this clause referred to
as the `Chief Actuary'), shall establish--
``(aa) actuarial guidelines for the submission of bid
information under this paragraph; and
``(bb) bidding rules that are appropriate to ensure
accurate bids and fair competition among MA plans.
``(II) Denial of bid amounts.--The Secretary shall deny
monthly bid amounts submitted under subparagraph (A) that do
not meet the actuarial guidelines and rules established under
subclause (I).
``(III) Refusal to accept certain bids due to
misrepresentations and failures to adequately meet
requirements.--In the case where the Secretary determines
that information submitted by an MA organization under
subparagraph (A) contains consistent misrepresentations and
failures to adequately meet requirements of the organization,
the Secretary may refuse to accept any additional such bid
amounts from the organization for the plan year and the Chief
Actuary shall, if the Chief Actuary determines that the
actuaries of the organization were complicit in those
misrepresentations and failures, report those actuaries to
the Actuarial Board for Counseling and Discipline.''.
(3) Effective date.--The amendments made by this subsection
shall apply to bid amounts submitted on or after January 1,
2012.
(e) MA Local Plan Service Areas.--
(1) In general.--Section 1853(d) of the Social Security Act
(42 U.S.C. 1395w-23(d)) is amended--
(A) in the subsection heading, by striking ``MA Region''
and inserting ``MA Region; MA Local Plan Service Area'';
(B) in paragraph (1), by striking subparagraph (A) and
inserting the following:
``(A) with respect to an MA local plan--
``(i) for years before 2012, an MA local area (as defined
in paragraph (2)); and
``(ii) for 2012 and succeeding years, a service area that
is an entire urban or rural area, as applicable (as described
in paragraph (5)); and''; and
(C) by adding at the end the following new paragraph:
``(5) MA local plan service area.--For 2012 and succeeding
years, the service area for an MA local plan shall be an
entire urban or rural area in each State as follows:
``(A) Urban areas.--
``(i) In general.--Subject to clause (ii) and subparagraphs
(C) and (D), the service area for an MA local plan in an
urban area shall be the Core Based Statistical Area (in this
paragraph referred to as a `CBSA') or, if applicable, a
conceptually similar alternative classification, as defined
by the Director of the Office of Management and Budget.
``(ii) CBSA covering more than one state.--In the case of a
CBSA (or alternative classification) that covers more than
one State, the Secretary shall divide the CBSA (or
alternative classification) into separate service areas with
respect to each State covered by the CBSA (or alternative
classification).
``(B) Rural areas.--Subject to subparagraphs (C) and (D),
the service area for an MA local plan in a rural area shall
be a county that does not qualify for inclusion in a CBSA (or
alternative classification), as defined by the Director of
the Office of Management and Budget.
``(C) Refinements to service areas.--For 2015 and
succeeding years, in order to reflect actual patterns of
health care service utilization, the Secretary may adjust the
boundaries of service areas for MA local plans in urban areas
and rural areas under subparagraphs (A) and (B),
respectively, but may only do so based on recent analyses of
actual patterns of care.
``(D) Additional authority to make limited exceptions to
service area requirements for ma local plans.--The Secretary
may, in addition to any adjustments under subparagraph (C),
make limited exceptions to service area requirements
otherwise applicable under this part for MA local plans that
have in effect (as of the date of enactment of the Patient
Protection and Affordable Care Act)--
``(i) agreements with another MA organization or MA plan
that preclude the offering of benefits throughout an entire
service area; or
``(ii) limitations in their structural capacity to support
adequate networks throughout an entire service area as a
result of the delivery system model of the MA local plan.''.
(2) Conforming amendments.--
(A) In general.--
(i) Section 1851(b)(1) of the Social Security Act (42
U.S.C. 1395w-21(b)(1)) is amended by striking subparagraph
(C).
(ii) Section 1853(b)(1)(B)(i) of such Act (42 U.S.C. 1395w-
23(b)(1)(B)(i))--
(I) in the matter preceding subclause (I), by striking ``MA
payment area'' and inserting ``MA local area (as defined in
subsection (d)(2))''; and
(II) in subclause (I), by striking ``MA payment area'' and
inserting ``MA local area (as so defined)''.
(iii) Section 1853(b)(4) of such Act (42 U.S.C. 1395w-
23(b)(4)) is amended by striking ``Medicare Advantage payment
area'' and inserting ``MA local area (as so defined)''.
(iv) Section 1853(c)(1) of such Act (42 U.S.C. 1395w-
23(c)(1)) is amended--
(I) in the matter preceding subparagraph (A), by striking
``a Medicare Advantage payment area that is''; and
(II) in subparagraph (D)(i), by striking ``MA payment
area'' and inserting ``MA local area (as defined in
subsection (d)(2))''.
(v) Section 1854 of such Act (42 U.S.C. 1395w-24) is
amended by striking subsection (h).
(B) Effective date.--The amendments made by this paragraph
shall take effect on January 1, 2012.
(f) Performance Bonuses.--
(1) MA plans.--
(A) In general.--Section 1853 of the Social Security Act
(42 U.S.C. 1395w-23) is amended by adding at the end the
following new subsection:
``(n) Performance Bonuses.--
``(1) Care coordination and management performance bonus.--
``(A) In general.--For years beginning with 2014, subject
to subparagraph (B), in the case of an MA plan that conducts
1 or more programs described in subparagraph (C) with respect
to the year, the Secretary shall, in addition to any other
payment provided under this part, make monthly payments, with
respect to coverage of an individual under this part, to the
MA plan in an amount equal to the product of--
``(i) 0.5 percent of the national monthly per capita cost
for expenditures for individuals enrolled under the original
medicare fee-for-service program for the year; and
``(ii) the total number of programs described in clauses
(i) through (ix) of subparagraph (C) that the Secretary
determines the plan is conducting for the year under such
subparagraph.
``(B) Limitation.--In no case may the total amount of
payment with respect to a year under subparagraph (A) be
greater than 2 percent of the national monthly per capita
cost for expenditures for individuals enrolled under the
original medicare fee-for-service program for the year, as
determined prior to the application of risk adjustment under
paragraph (4).
``(C) Programs described.--The following programs are
described in this paragraph:
``(i) Care management programs that--
``(I) target individuals with 1 or more chronic conditions;
``(II) identify gaps in care; and
``(III) facilitate improved care by using additional
resources like nurses, nurse practitioners, and physician
assistants.
``(ii) Programs that focus on patient education and self-
management of health conditions, including interventions
that--
``(I) help manage chronic conditions;
``(II) reduce declines in health status; and
``(III) foster patient and provider collaboration.
``(iii) Transitional care interventions that focus on care
provided around a hospital inpatient episode, including
programs that target post-discharge patient care in order to
reduce unnecessary health complications and readmissions.
``(iv) Patient safety programs, including provisions for
hospital-based patient safety programs in contracts that the
Medicare Advantage organization offering the MA plan has with
hospitals.
``(v) Financial policies that promote systematic
coordination of care by primary care physicians across the
full spectrum of specialties and sites of care, such as
medical homes, capitation arrangements, or pay-for-
performance programs.
``(vi) Programs that address, identify, and ameliorate
health care disparities among principal at-risk
subpopulations.
``(vii) Medication therapy management programs that are
more extensive than is required under section 1860D-4(c) (as
determined by the Secretary).
``(viii) Health information technology programs, including
clinical decision support and other tools to facilitate data
collection and ensure patient-centered, appropriate care.
``(ix) Such other care management and coordination programs
as the Secretary determines appropriate.
``(D) Conduct of program in urban and rural areas.--An MA
plan may conduct a program described in subparagraph (C) in a
manner appropriate for an urban or rural area, as applicable.
``(E) Reporting of data.--Each Medicare Advantage
organization shall provide to the Secretary the information
needed to determine whether they are eligible for a care
coordination and management performance bonus at a time and
in a manner specified by the Secretary.
``(F) Periodic auditing.--The Secretary shall provide for
the annual auditing of programs described in subparagraph (C)
for which an MA plan receives a care coordination and
management performance bonus under this paragraph. The
Comptroller General shall monitor auditing activities
conducted under this subparagraph.
``(2) Quality performance bonuses.--
``(A) Quality bonus.--For years beginning with 2014, the
Secretary shall, in addition to any other payment provided
under this part, make monthly payments, with respect to
coverage of an individual under this part, to an MA plan that
achieves at least a 3 star rating
[[Page H2006]]
(or comparable rating) on a rating system described in
subparagraph (C) in an amount equal to--
``(i) in the case of a plan that achieves a 3 star rating
(or comparable rating) on such system 2 percent of the
national monthly per capita cost for expenditures for
individuals enrolled under the original medicare fee-for-
service program for the year; and
``(ii) in the case of a plan that achieves a 4 or 5 star
rating (or comparable rating on such system, 4 percent of
such national monthly per capita cost for the year.
``(B) Improved quality bonus.--For years beginning with
2014, in the case of an MA plan that does not receive a
quality bonus under subparagraph (A) and is an improved
quality MA plan with respect to the year (as identified by
the Secretary), the Secretary shall, in addition to any other
payment provided under this part, make monthly payments, with
respect to coverage of an individual under this part, to the
MA plan in an amount equal to 1 percent of such national
monthly per capita cost for the year.
``(C) Use of rating system.--For purposes of subparagraph
(A), a rating system described in this paragraph is--
``(i) a rating system that uses up to 5 stars to rate
clinical quality and enrollee satisfaction and performance at
the Medicare Advantage contract or MA plan level; or
``(ii) such other system established by the Secretary that
provides for the determination of a comparable quality
performance rating to the rating system described in clause
(i).
``(D) Data used in determining score.--
``(i) In general.--The rating of an MA plan under the
rating system described in subparagraph (C) with respect to a
year shall be based on based on the most recent data
available.
``(ii) Plans that fail to report data.--An MA plan which
does not report data that enables the Secretary to rate the
plan for purposes of subparagraph (A) or identify the plan
for purposes of subparagraph (B) shall be counted, for
purposes of such rating or identification, as having the
lowest plan performance rating and the lowest percentage
improvement, respectively.
``(3) Quality bonus for new and low enrollment ma plans.--
``(A) New ma plans.--For years beginning with 2014, in the
case of an MA plan that first submits a bid under section
1854(a)(1)(A) for 2012 or a subsequent year, only receives
enrollments made during the coverage election periods
described in section 1851(e), and is not able to receive a
bonus under subparagraph (A) or (B) of paragraph (2) for the
year, the Secretary shall, in addition to any other payment
provided under this part, make monthly payments, with respect
to coverage of an individual under this part, to the MA plan
in an amount equal to 2 percent of national monthly per
capita cost for expenditures for individuals enrolled under
the original medicare fee-for-service program for the year.
In its fourth year of operation, the MA plan shall be paid in
the same manner as other MA plans with comparable enrollment.
``(B) Low enrollment plans.--For years beginning with 2014,
in the case of an MA plan that has low enrollment (as defined
by the Secretary) and would not otherwise be able to receive
a bonus under subparagraph (A) or (B) of paragraph (2) or
subparagraph (A) of this paragraph for the year (referred to
in this subparagraph as a `low enrollment plan'), the
Secretary shall use a regional or local mean of the rating of
all MA plans in the region or local area, as determined
appropriate by the Secretary, on measures used to determine
whether MA plans are eligible for a quality or an improved
quality bonus, as applicable, to determine whether the low
enrollment plan is eligible for a bonus under such a
subparagraph.
``(4) Risk adjustment.--The Secretary shall risk adjust a
performance bonus under this subsection in the same manner as
the Secretary risk adjusts beneficiary rebates described in
section 1854(b)(1)(C).
``(5) Notification.--The Secretary, in the annual
announcement required under subsection (b)(1)(B) for 2014 and
each succeeding year, shall notify the Medicare Advantage
organization of any performance bonus (including a care
coordination and management performance bonus under paragraph
(1), a quality performance bonus under paragraph (2), and a
quality bonus for new and low enrollment plans under
paragraph (3)) that the organization will receive under this
subsection with respect to the year. The Secretary shall
provide for the publication of the information described in
the previous sentence on the Internet website of the Centers
for Medicare & Medicaid Services.''
(B) Conforming amendment.--Section 1853(a)(1)(B) of the
Social Security Act (42 U.S.C. 1395w-23(a)(1)(B)) is
amended--
(i) in clause (i), by inserting ``and any performance bonus
under subsection (n)'' before the period at the end; and
(ii) in clause (ii), by striking ``(G)'' and inserting
``(G), plus the amount (if any) of any performance bonus
under subsection (n)''.
(2) Application of performance bonuses to ma regional
plans.--Section 1858 of the Social Security Act (42 U.S.C.
1395w-27a) is amended--
(A) in subsection (f)(1), by striking ``subsection (e)''
and inserting ``subsections (e) and (i)''; and
(B) by adding at the end the following new subsection:
``(i) Application of Performance Bonuses to MA Regional
Plans.--For years beginning with 2014, the Secretary shall
apply the performance bonuses under section 1853(n) (relating
to bonuses for care coordination and management, quality
performance, and new and low enrollment MA plans) to MA
regional plans in a similar manner as such performance
bonuses apply to MA plans under such subsection.''.
(g) Grandfathering Supplemental Benefits for Current
Enrollees After Implementation of Competitive Bidding.--
Section 1853 of the Social Security Act (42 U.S.C. 1395w-23),
as amended by subsection (f), is amended by adding at the end
the following new subsection:
``(o) Grandfathering Supplemental Benefits for Current
Enrolles After Implementation of Competitive Bidding.--
``(1) Identification of areas.--The Secretary shall
identify MA local areas in which, with respect to 2009,
average bids submitted by an MA organization under section
1854(a) for MA local plans in the area are not greater than
75 percent of the adjusted average per capita cost for the
year involved, determined under section 1876(a)(4), for the
area for individuals who are not enrolled in an MA plan under
this part for the year, but adjusted to exclude costs
attributable to payments under section 1848(o), 1886(n), and
1886(h).
``(2) Election to provide rebates to grandfathered
enrollees.--
``(A) In general.--For years beginning with 2012, each
Medicare Advantage organization offering an MA local plan in
an area identified by the Secretary under paragraph (1) may
elect to provide rebates to grandfathered enrollees under
section 1854(b)(1)(C). In the case where an MA organization
makes such an election, the monthly per capita dollar amount
of such rebates shall not exceed the applicable amount for
the year (as defined in subparagraph (B)).
``(B) Applicable amount.--For purposes of this subsection,
the term `applicable amount' means--
``(i) for 2012, the monthly per capita dollar amount of
such rebates provided to enrollees under the MA local plan
with respect to 2011; and
``(ii) for a subsequent year, 95 percent of the amount
determined under this subparagraph for the preceding year.
``(3) Special rules for plans in identified areas.--
Notwithstanding any other provision of this part, the
following shall apply with respect to each Medicare Advantage
organization offering an MA local plan in an area identified
by the Secretary under paragraph (1) that makes an election
described in paragraph (2):
``(A) Payments.--The amount of the monthly payment under
this section to the Medicare Advantage organization, with
respect to coverage of a grandfathered enrollee under this
part in the area for a month, shall be equal to--
``(i) for 2012 and 2013, the sum of--
``(I) the bid amount under section 1854(a) for the MA local
plan; and
``(II) the applicable amount (as defined in paragraph
(2)(B)) for the MA local plan for the year.
``(ii) for 2014 and subsequent years, the sum of--
``(I) the MA competitive benchmark amount under subsection
(j)(1)(A)(i) for the area for the month, adjusted, only to
the extent the Secretary determines necessary, to account for
induced utilization as a result of rebates provided to
grandfathered enrollees (except that such adjustment shall
not exceed 0.5 percent of such MA competitive benchmark
amount); and
``(II) the applicable amount (as so defined) for the MA
local plan for the year.
``(B) Requirement to submit bids under competitive
bidding.--The Medicare Advantage organization shall submit a
single bid amount under section 1854(a) for the MA local
plan. The Medicare Advantage organization shall remove from
such bid amount any effects of induced demand for care that
may result from the higher rebates available to grandfathered
enrollees under this subsection.
``(C) Nonapplication of bonus payments and any other
rebates.--The Medicare Advantage organization offering the MA
local plan shall not be eligible for any bonus payment under
subsection (n) or any rebate under this part (other than as
provided under this subsection) with respect to grandfathered
enrollees.
``(D) Nonapplication of uniform bid and premium amounts to
grandfathered enrollees.--Section 1854(c) shall not apply
with respect to the MA local plan.
``(E) Nonapplication of limitation on application of plan
rebates toward payment of part b premium.--Notwithstanding
clause (iii) of section 1854(b)(1)(C), in the case of a
grandfathered enrollee, a rebate under such section may be
used for the purpose described in clause (ii)(III) of such
section.
``(F) Risk adjustment.--The Secretary shall risk adjust
rebates to grandfathered enrollees under this subsection in
the same manner as the Secretary risk adjusts beneficiary
rebates described in section 1854(b)(1)(C).
``(4) Definition of grandfathered enrollee.--In this
subsection, the term `grandfathered enrollee' means an
individual who is enrolled (effective as of the date of
enactment of this subsection) in an MA local plan in an area
that is identified by the Secretary under paragraph (1).''.
(h) Transitional Extra Benefits.--Section 1853 of the
Social Security Act (42 U.S.C. 1395w-23), as amended by
subsections (f) and (g), is amended by adding at the end the
following new subsection:
``(p) Transitional Extra Benefits.--
``(1) In general.--For years beginning with 2012, the
Secretary shall provide transitional rebates under section
1854(b)(1)(C) for the provision of extra benefits (as
specified by the Secretary) to enrollees described in
paragraph (2).
``(2) Enrollees described.--An enrollee described in this
paragraph is an individual who--
``(A) enrolls in an MA local plan in an applicable area;
and
``(B) experiences a significant reduction in extra benefits
described in clause (ii) of section 1854(b)(1)(C) as a result
of competitive bidding under this part (as determined by the
Secretary).
``(3) Applicable areas.--In this subsection, the term
`applicable area' means the following:
[[Page H2007]]
``(A) The 2 largest metropolitan statistical areas, if the
Secretary determines that the total amount of such extra
benefits for each enrollee for the month in those areas is
greater than $100.
``(B) A county where--
``(i) the MA area-specific non-drug monthly benchmark
amount for a month in 2011 is equal to the legacy urban floor
amount (as described in subsection (c)(1)(B)(iii)), as
determined by the Secretary for the area for 2011;
``(ii) the percentage of Medicare Advantage eligible
beneficiaries in the county who are enrolled in an MA plan
for 2009 is greater than 30 percent (as determined by the
Secretary); and
``(iii) average bids submitted by an MA organization under
section 1854(a) for MA local plans in the county for 2011 are
not greater than the adjusted average per capita cost for the
year involved, determined under section 1876(a)(4), for the
county for individuals who are not enrolled in an MA plan
under this part for the year, but adjusted to exclude costs
attributable to payments under section 1848(o), 1886(n), and
1886(h).
``(C) If the Secretary determines appropriate, a county
contiguous to an area or county described in subparagraph (A)
or (B), respectively.
``(4) Review of plan bids.--In the case of a bid submitted
by an MA organization under section 1854(a) for an MA local
plan in an applicable area, the Secretary shall review such
bid in order to ensure that extra benefits (as specified by
the Secretary) are provided to enrollees described in
paragraph (2).
``(5) Funding.--The Secretary shall provide for the
transfer from the Federal Hospital Insurance Trust Fund under
section 1817 and the Federal Supplementary Medical Insurance
Trust Fund established under section 1841, in such proportion
as the Secretary determines appropriate, of an amount not to
exceed $5,000,000,000 for the period of fiscal years 2012
through 2019 for the purpose of providing transitional
rebates under section 1854(b)(1)(C) for the provision of
extra benefits under this subsection.''.
(i) Nonapplication of Competitive Bidding and Related
Provisions and Clarification of MA Payment Area for PACE
Programs.--
(1) Nonapplication of competitive bidding and related
provisions for pace programs.--Section 1894 of the Social
Security Act (42 U.S.C. 1395eee) is amended--
(A) by redesignating subsections (h) and (i) as subsections
(i) and (j), respectively;
(B) by inserting after subsection (g) the following new
subsection:
``(h) Nonapplication of Competitive Bidding and Related
Provisions Under Part C.--With respect to a PACE program
under this section, the following provisions (and regulations
relating to such provisions) shall not apply:
``(1) Section 1853(j)(1)(A)(i), relating to MA area-
specific non-drug monthly benchmark amount being based on
competitive bids.
``(2) Section 1853(d)(5), relating to the establishment of
MA local plan service areas.
``(3) Section 1853(n), relating to the payment of
performance bonuses.
``(4) Section 1853(o), relating to grandfathering
supplemental benefits for current enrollees after
implementation of competitive bidding.
``(5) Section 1853(p), relating to transitional extra
benefits.''.
(2) Special rule for ma payment area for pace programs.--
Section 1853(d) of the Social Security Act (42 U.S.C. 1395w-
23(d)), as amended by subsection (e), is amended by adding at
the end the following new paragraph:
``(6) Special rule for ma payment area for pace programs.--
For years beginning with 2012, in the case of a PACE program
under section 1894, the MA payment area shall be the MA local
area (as defined in paragraph (2)).''.
SEC. 3202. BENEFIT PROTECTION AND SIMPLIFICATION.
(a) Limitation on Variation of Cost Sharing for Certain
Benefits.--
(1) In general.--Section 1852(a)(1)(B) of the Social
Security Act (42 U.S.C. 1395w-22(a)(1)(B)) is amended--
(A) in clause (i), by inserting ``, subject to clause
(iii),'' after ``and B or''; and
(B) by adding at the end the following new clauses:
``(iii) Limitation on variation of cost sharing for certain
benefits.--Subject to clause (v), cost-sharing for services
described in clause (iv) shall not exceed the cost-sharing
required for those services under parts A and B.
``(iv) Services described.--The following services are
described in this clause:
``(I) Chemotherapy administration services.
``(II) Renal dialysis services (as defined in section
1881(b)(14)(B)).
``(III) Skilled nursing care.
``(IV) Such other services that the Secretary determines
appropriate (including services that the Secretary determines
require a high level of predictability and transparency for
beneficiaries).
``(v) Exception.--In the case of services described in
clause (iv) for which there is no cost-sharing required under
parts A and B, cost-sharing may be required for those
services in accordance with clause (i).''.
(2) Effective date.--The amendments made by this subsection
shall apply to plan years beginning on or after January 1,
2011.
(b) Application of Rebates, Performance Bonuses, and
Premiums.--
(1) Application of rebates.--Section 1854(b)(1)(C) of the
Social Security Act (42 U.S.C. 1395w-24(b)(1)(C)) is
amended--
(A) in clause (ii), by striking ``rebate.--A rebate'' and
inserting ``rebate for plan years before 2012.--For plan
years before 2012, a rebate'';
(B) by redesignating clauses (iii) and (iv) as clauses (iv)
and (v); and
(C) by inserting after clause (ii) the following new
clause:
``(iii) Form of rebate for plan year 2012 and subsequent
plan years.--For plan years beginning on or after January 1,
2012, a rebate required under this subparagraph may not be
used for the purpose described in clause (ii)(III) and shall
be provided through the application of the amount of the
rebate in the following priority order:
``(I) First, to use the most significant share to
meaningfully reduce cost-sharing otherwise applicable for
benefits under the original medicare fee-for-service program
under parts A and B and for qualified prescription drug
coverage under part D, including the reduction of any
deductibles, copayments, and maximum limitations on out-of-
pocket expenses otherwise applicable. Any reduction of
maximum limitations on out-of-pocket expenses under the
preceding sentence shall apply to all benefits under the
original medicare fee-for-service program option. The
Secretary may provide guidance on meaningfully reducing cost-
sharing under this subclause, except that such guidance may
not require a particular amount of cost-sharing or reduction
in cost-sharing.
``(II) Second, to use the next most significant share to
meaningfully provide coverage of preventive and wellness
health care benefits (as defined by the Secretary) which are
not benefits under the original medicare fee-for-service
program, such as smoking cessation, a free flu shot, and an
annual physical examination.
``(III) Third, to use the remaining share to meaningfully
provide coverage of other health care benefits which are not
benefits under the original medicare fee-for-service program,
such as eye examinations and dental coverage, and are not
benefits described in subclause (II).''.
(2) Application of performance bonuses.--Section 1853(n) of
the Social Security Act, as added by section 3201(f), is
amended by adding at the end the following new paragraph:
``(6) Application of performance bonuses.--For plan years
beginning on or after January 1, 2014, any performance bonus
paid to an MA plan under this subsection shall be used for
the purposes, and in the priority order, described in
subclauses (I) through (III) of section
1854(b)(1)(C)(iii).''.
(3) Application of ma monthly supplementary beneficiary
premium.--Section 1854(b)(2)(C) of the Social Security Act
(42 U.S.C. 1395w-24(b)(2)(C)) is amended--
(A) by striking ``Premium.--The term'' and inserting
``premium.--
``(i) In general.--The term''; and
(B) by adding at the end the following new clause:
``(ii) Application of ma monthly supplementary beneficiary
premium.--For plan years beginning on or after January 1,
2012, any MA monthly supplementary beneficiary premium
charged to an individual enrolled in an MA plan shall be used
for the purposes, and in the priority order, described in
subclauses (I) through (III) of paragraph (1)(C)(iii).''.
SEC. 3203. APPLICATION OF CODING INTENSITY ADJUSTMENT DURING
MA PAYMENT TRANSITION.
Section 1853(a)(1)(C) of the Social Security Act (42 U.S.C.
1395w-23(a)(1)(C)) is amended by adding at the end the
following new clause:
``(iii) Application of coding intensity adjustment for 2011
and subsequent years.--
``(I) Requirement to apply in 2011 through 2013.--In order
to ensure payment accuracy, the Secretary shall conduct an
analysis of the differences described in clause (ii)(I). The
Secretary shall ensure that the results of such analysis are
incorporated into the risk scores for 2011, 2012, and 2013.
``(II) Authority to apply in 2014 and subsequent years.--
The Secretary may, as appropriate, incorporate the results of
such analysis into the risk scores for 2014 and subsequent
years.''.
SEC. 3204. SIMPLIFICATION OF ANNUAL BENEFICIARY ELECTION
PERIODS.
(a) Annual 45-day Period for Disenrollment From MA Plans To
Elect To Receive Benefits Under the Original Medicare Fee-
for-service Program.--
(1) In general.--Section 1851(e)(2)(C) of the Social
Security Act (42 U.S.C. 1395w-1(e)(2)(C)) is amended to read
as follows:
``(C) Annual 45-day period for disenrollment from ma plans
to elect to receive benefits under the original medicare fee-
for-service program.--Subject to subparagraph (D), at any
time during the first 45 days of a year (beginning with
2011), an individual who is enrolled in a Medicare Advantage
plan may change the election under subsection (a)(1), but
only with respect to coverage under the original medicare
fee-for-service program under parts A and B, and may elect
qualified prescription drug coverage in accordance with
section 1860D-1.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply with respect to 2011 and succeeding years.
(b) Timing of the Annual, Coordinated Election Period Under
Parts C and D.--Section 1851(e)(3)(B) of the Social Security
Act (42 U.S.C. 1395w-1(e)(3)(B)) is amended--
(1) in clause (iii), by striking ``and'' at the end;
(2) in clause (iv)--
(A) by striking ``and succeeding years'' and inserting ``,
2008, 2009, and 2010''; and
(B) by striking the period at the end and inserting ``;
and''; and
(3) by adding at the end the following new clause:
``(v) with respect to 2012 and succeeding years, the period
beginning on October 15 and ending on December 7 of the year
before such year.''.
[[Page H2008]]
SEC. 3205. EXTENSION FOR SPECIALIZED MA PLANS FOR SPECIAL
NEEDS INDIVIDUALS.
(a) Extension of SNP Authority.--Section 1859(f)(1) of the
Social Security Act (42 U.S.C. 1395w-28(f)(1)), as amended by
section 164(a) of the Medicare Improvements for Patients and
Providers Act of 2008 (Public Law 110-275), is amended by
striking ``2011'' and inserting ``2014''.
(b) Authority To Apply Frailty Adjustment Under PACE
Payment Rules.--Section 1853(a)(1)(B) of the Social Security
Act (42 U.S.C. 1395w-23(a)(1)(B)) is amended by adding at the
end the following new clause:
``(iv) Authority to apply frailty adjustment under pace
payment rules for certain specialized ma plans for special
needs individuals.--
``(I) In general.--Notwithstanding the preceding provisions
of this paragraph, for plan year 2011 and subsequent plan
years, in the case of a plan described in subclause (II), the
Secretary may apply the payment rules under section 1894(d)
(other than paragraph (3) of such section) rather than the
payment rules that would otherwise apply under this part, but
only to the extent necessary to reflect the costs of treating
high concentrations of frail individuals.
``(II) Plan described.--A plan described in this subclause
is a specialized MA plan for special needs individuals
described in section 1859(b)(6)(B)(ii) that is fully
integrated with capitated contracts with States for Medicaid
benefits, including long-term care, and that have similar
average levels of frailty (as determined by the Secretary) as
the PACE program.''.
(c) Transition and Exception Regarding Restriction on
Enrollment.--Section 1859(f) of the Social Security Act (42
U.S.C. 1395w-28(f)) is amended by adding at the end the
following new paragraph:
``(6) Transition and exception regarding restriction on
enrollment.--
``(A) In general.--Subject to subparagraph (C), the
Secretary shall establish procedures for the transition of
applicable individuals to--
``(i) a Medicare Advantage plan that is not a specialized
MA plan for special needs individuals (as defined in
subsection (b)(6)); or
``(ii) the original medicare fee-for-service program under
parts A and B.
``(B) Applicable individuals.--For purposes of clause (i),
the term `applicable individual' means an individual who--
``(i) is enrolled under a specialized MA plan for special
needs individuals (as defined in subsection (b)(6)); and
``(ii) is not within the 1 or more of the classes of
special needs individuals to which enrollment under the plan
is restricted to.
``(C) Exception.--The Secretary shall provide for an
exception to the transition described in subparagraph (A) for
a limited period of time for individuals enrolled under a
specialized MA plan for special needs individuals described
in subsection (b)(6)(B)(ii) who are no longer eligible for
medical assistance under title XIX.
``(D) Timeline for initial transition.--The Secretary shall
ensure that applicable individuals enrolled in a specialized
MA plan for special needs individuals (as defined in
subsection (b)(6)) prior to January 1, 2010, are transitioned
to a plan or the program described in subparagraph (A) by not
later than January 1, 2013.''.
(d) Temporary Extension of Authority To Operate but No
Service Area Expansion for Dual Special Needs Plans That Do
Not Meet Certain Requirements.--Section 164(c)(2) of the
Medicare Improvements for Patients and Providers Act of 2008
(Public Law 110-275) is amended by striking ``December 31,
2010'' and inserting ``December 31, 2012''.
(e) Authority To Require Special Needs Plans Be NCQA
Approved.--Section 1859(f) of the Social Security Act (42
U.S.C. 1395w-28(f)), as amended by subsections (a) and (c),
is amended--
(1) in paragraph (2), by adding at the end the following
new subparagraph:
``(C) If applicable, the plan meets the requirement
described in paragraph (7).'';
(2) in paragraph (3), by adding at the end the following
new subparagraph:
``(E) If applicable, the plan meets the requirement
described in paragraph (7).'';
(3) in paragraph (4), by adding at the end the following
new subparagraph:
``(C) If applicable, the plan meets the requirement
described in paragraph (7).''; and
(4) by adding at the end the following new paragraph:
``(7) Authority to require special needs plans be ncqa
approved.--For 2012 and subsequent years, the Secretary shall
require that a Medicare Advantage organization offering a
specialized MA plan for special needs individuals be approved
by the National Committee for Quality Assurance (based on
standards established by the Secretary).''.
(f) Risk Adjustment.--Section 1853(a)(1)(C) of the Social
Security Act (42 U.S.C. 1395i-23(a)(1)(C)) is amended by
adding at the end the following new clause:
``(iii) Improvements to risk adjustment for special needs
individuals with chronic health conditions.--
``(I) In general.--For 2011 and subsequent years, for
purposes of the adjustment under clause (i) with respect to
individuals described in subclause (II), the Secretary shall
use a risk score that reflects the known underlying risk
profile and chronic health status of similar individuals.
Such risk score shall be used instead of the default risk
score for new enrollees in Medicare Advantage plans that are
not specialized MA plans for special needs individuals (as
defined in section 1859(b)(6)).
``(II) Individuals described.--An individual described in
this subclause is a special needs individual described in
subsection (b)(6)(B)(iii) who enrolls in a specialized MA
plan for special needs individuals on or after January 1,
2011.
``(III) Evaluation.--For 2011 and periodically thereafter,
the Secretary shall evaluate and revise the risk adjustment
system under this subparagraph in order to, as accurately as
possible, account for higher medical and care coordination
costs associated with frailty, individuals with multiple,
comorbid chronic conditions, and individuals with a diagnosis
of mental illness, and also to account for costs that may be
associated with higher concentrations of beneficiaries with
those conditions.
``(IV) Publication of evaluation and revisions.--The
Secretary shall publish, as part of an announcement under
subsection (b), a description of any evaluation conducted
under subclause (III) during the preceding year and any
revisions made under such subclause as a result of such
evaluation.''.
(g) Technical Correction.--Section 1859(f)(5) of the Social
Security Act (42 U.S.C. 1395w-28(f)(5)) is amended, in the
matter preceding subparagraph (A), by striking ``described in
subsection (b)(6)(B)(i)''.
SEC. 3206. EXTENSION OF REASONABLE COST CONTRACTS.
Section 1876(h)(5)(C)(ii) of the Social Security Act (42
U.S.C. 1395mm(h)(5)(C)(ii)) is amended, in the matter
preceding subclause (I), by striking ``January 1, 2010'' and
inserting ``January 1, 2013''.
SEC. 3207. TECHNICAL CORRECTION TO MA PRIVATE FEE-FOR-SERVICE
PLANS.
For plan year 2011 and subsequent plan years, to the extent
that the Secretary of Health and Human Services is applying
the 2008 service area extension waiver policy (as modified in
the April 11, 2008, Centers for Medicare & Medicaid Services'
memorandum with the subject ``2009 Employer Group Waiver-
Modification of the 2008 Service Area Extension Waiver
Granted to Certain MA Local Coordinated Care Plans'') to
Medicare Advantage coordinated care plans, the Secretary
shall extend the application of such waiver policy to
employers who contract directly with the Secretary as a
Medicare Advantage private fee-for-service plan under section
1857(i)(2) of the Social Security Act (42 U.S.C. 1395w-
27(i)(2)) and that had enrollment as of October 1, 2009.
SEC. 3208. MAKING SENIOR HOUSING FACILITY DEMONSTRATION
PERMANENT.
(a) In General.--Section 1859 of the Social Security Act
(42 U.S.C. 1395w-28) is amended by adding at the end the
following new subsection:
``(g) Special Rules for Senior Housing Facility Plans.--
``(1) In general.--In the case of a Medicare Advantage
senior housing facility plan described in paragraph (2),
notwithstanding any other provision of this part to the
contrary and in accordance with regulations of the Secretary,
the service area of such plan may be limited to a senior
housing facility in a geographic area.
``(2) Medicare advantage senior housing facility plan
described.--For purposes of this subsection, a Medicare
Advantage senior housing facility plan is a Medicare
Advantage plan that--
``(A) restricts enrollment of individuals under this part
to individuals who reside in a continuing care retirement
community (as defined in section 1852(l)(4)(B));
``(B) provides primary care services onsite and has a ratio
of accessible physicians to beneficiaries that the Secretary
determines is adequate;
``(C) provides transportation services for beneficiaries to
specialty providers outside of the facility; and
``(D) has participated (as of December 31, 2009) in a
demonstration project established by the Secretary under
which such a plan was offered for not less than 1 year.''.
(b) Effective Date.--The amendment made by this section
shall take effect on January 1, 2010, and shall apply to plan
years beginning on or after such date.
SEC. 3209. AUTHORITY TO DENY PLAN BIDS.
(a) In General.--Section 1854(a)(5) of the Social Security
Act (42 U.S.C. 1395w-24(a)(5)) is amended by adding at the
end the following new subparagraph:
``(C) Rejection of bids.--
``(i) In general.--Nothing in this section shall be
construed as requiring the Secretary to accept any or every
bid submitted by an MA organization under this subsection.
``(ii) Authority to deny bids that propose significant
increases in cost sharing or decreases in benefits.--The
Secretary may deny a bid submitted by an MA organization for
an MA plan if it proposes significant increases in cost
sharing or decreases in benefits offered under the plan.''.
(b) Application Under Part D.--Section 1860D-11(d) of such
Act (42 U.S.C. 1395w-111(d)) is amended by adding at the end
the following new paragraph:
``(3) Rejection of bids.--Paragraph (5)(C) of section
1854(a) shall apply with respect to bids submitted by a PDP
sponsor under subsection (b) in the same manner as such
paragraph applies to bids submitted by an MA organization
under such section 1854(a).''.
(c) Effective Date.--The amendments made by this section
shall apply to bids submitted for contract years beginning on
or after January 1, 2011.
SEC. 3210. DEVELOPMENT OF NEW STANDARDS FOR CERTAIN MEDIGAP
PLANS.
(a) In General.--Section 1882 of the Social Security Act
(42 U.S.C. 1395ss) is amended by adding at the end the
following new subsection:
``(y) Development of New Standards for Certain Medicare
Supplemental Policies.--
``(1) In general.--The Secretary shall request the National
Association of Insurance Commissioners to review and revise
the standards for benefit packages described in paragraph (2)
[[Page H2009]]
under subsection (p)(1), to otherwise update standards to
include requirements for nominal cost sharing to encourage
the use of appropriate physicians' services under part B.
Such revisions shall be based on evidence published in peer-
reviewed journals or current examples used by integrated
delivery systems and made consistent with the rules
applicable under subsection (p)(1)(E) with the reference to
the `1991 NAIC Model Regulation' deemed a reference to the
NAIC Model Regulation as published in the Federal Register on
December 4, 1998, and as subsequently updated by the National
Association of Insurance Commissioners to reflect previous
changes in law and the reference to `date of enactment of
this subsection' deemed a reference to the date of enactment
of the Patient Protection and Affordable Care Act. To the
extent practicable, such revision shall provide for the
implementation of revised standards for benefit packages as
of January 1, 2015.
``(2) Benefit packages described.--The benefit packages
described in this paragraph are benefit packages classified
as `C' and `F'.''.
(b) Conforming Amendment.--Section 1882(o)(1) of the Social
Security Act (42 U.S.C. 1395ss(o)(1)) is amended by striking
``, and (w)'' and inserting ``(w), and (y)''.
Subtitle D--Medicare Part D Improvements for Prescription Drug Plans
and MA-PD Plans
SEC. 3301. MEDICARE COVERAGE GAP DISCOUNT PROGRAM.
(a) Condition for Coverage of Drugs Under Part D.--Part D
of Title XVIII of the Social Security Act (42 U.S.C. 1395w-
101 et seq.), is amended by adding at the end the following
new section:
``condition for coverage of drugs under this part
``Sec. 1860D-43. (a) In General.--In order for coverage to
be available under this part for covered part D drugs (as
defined in section 1860D-2(e)) of a manufacturer, the
manufacturer must--
``(1) participate in the Medicare coverage gap discount
program under section 1860D-14A;
``(2) have entered into and have in effect an agreement
described in subsection (b) of such section with the
Secretary; and
``(3) have entered into and have in effect, under terms and
conditions specified by the Secretary, a contract with a
third party that the Secretary has entered into a contract
with under subsection (d)(3) of such section.
``(b) Effective Date.--Subsection (a) shall apply to
covered part D drugs dispensed under this part on or after
July 1, 2010.
``(c) Authorizing Coverage for Drugs Not Covered Under
Agreements.--Subsection (a) shall not apply to the dispensing
of a covered part D drug if--
``(1) the Secretary has made a determination that the
availability of the drug is essential to the health of
beneficiaries under this part; or
``(2) the Secretary determines that in the period beginning
on July 1, 2010, and ending on December 31, 2010, there were
extenuating circumstances.
``(d) Definition of Manufacturer.--In this section, the
term `manufacturer' has the meaning given such term in
section 1860D-14A(g)(5).''.
(b) Medicare Coverage Gap Discount Program.--Part D of
title XVIII of the Social Security Act (42 U.S.C. 1395w-101)
is amended by inserting after section 1860D-14 the following
new section:
``medicare coverage gap discount program
``Sec. 1860D-14A. (a) Establishment.--The Secretary shall
establish a Medicare coverage gap discount program (in this
section referred to as the `program') by not later than July
1, 2010. Under the program, the Secretary shall enter into
agreements described in subsection (b) with manufacturers and
provide for the performance of the duties described in
subsection (c)(1). The Secretary shall establish a model
agreement for use under the program by not later than April
1, 2010, in consultation with manufacturers, and allow for
comment on such model agreement.
``(b) Terms of Agreement.--
``(1) In general.--
``(A) Agreement.--An agreement under this section shall
require the manufacturer to provide applicable beneficiaries
access to discounted prices for applicable drugs of the
manufacturer.
``(B) Provision of discounted prices at the point-of-
sale.--Except as provided in subsection (c)(1)(A)(iii), such
discounted prices shall be provided to the applicable
beneficiary at the pharmacy or by the mail order service at
the point-of-sale of an applicable drug.
``(C) Timing of agreement.--
``(i) Special rule for 2010 and 2011.--In order for an
agreement with a manufacturer to be in effect under this
section with respect to the period beginning on July 1, 2010,
and ending on December 31, 2011, the manufacturer shall enter
into such agreement not later than May 1, 2010.
``(ii) 2012 and subsequent years.--In order for an
agreement with a manufacturer to be in effect under this
section with respect to plan year 2012 or a subsequent plan
year, the manufacturer shall enter into such agreement (or
such agreement shall be renewed under paragraph (4)(A)) not
later than January 30 of the preceding year.
``(2) Provision of appropriate data.--Each manufacturer
with an agreement in effect under this section shall collect
and have available appropriate data, as determined by the
Secretary, to ensure that it can demonstrate to the Secretary
compliance with the requirements under the program.
``(3) Compliance with requirements for administration of
program.--Each manufacturer with an agreement in effect under
this section shall comply with requirements imposed by the
Secretary or a third party with a contract under subsection
(d)(3), as applicable, for purposes of administering the
program, including any determination under clause (i) of
subsection (c)(1)(A) or procedures established under such
subsection (c)(1)(A).
``(4) Length of agreement.--
``(A) In general.--An agreement under this section shall be
effective for an initial period of not less than 18 months
and shall be automatically renewed for a period of not less
than 1 year unless terminated under subparagraph (B).
``(B) Termination.--
``(i) By the secretary.--The Secretary may provide for
termination of an agreement under this section for a knowing
and willful violation of the requirements of the agreement or
other good cause shown. Such termination shall not be
effective earlier than 30 days after the date of notice to
the manufacturer of such termination. The Secretary shall
provide, upon request, a manufacturer with a hearing
concerning such a termination, and such hearing shall take
place prior to the effective date of the termination with
sufficient time for such effective date to be repealed if the
Secretary determines appropriate.
``(ii) By a manufacturer.--A manufacturer may terminate an
agreement under this section for any reason. Any such
termination shall be effective, with respect to a plan year--
``(I) if the termination occurs before January 30 of a plan
year, as of the day after the end of the plan year; and
``(II) if the termination occurs on or after January 30 of
a plan year, as of the day after the end of the succeeding
plan year.
``(iii) Effectiveness of termination.--Any termination
under this subparagraph shall not affect discounts for
applicable drugs of the manufacturer that are due under the
agreement before the effective date of its termination.
``(iv) Notice to third party.--The Secretary shall provide
notice of such termination to a third party with a contract
under subsection (d)(3) within not less than 30 days before
the effective date of such termination.
``(c) Duties Described and Special Rule for Supplemental
Benefits.--
``(1) Duties described.--The duties described in this
subsection are the following:
``(A) Administration of program.--Administering the
program, including--
``(i) the determination of the amount of the discounted
price of an applicable drug of a manufacturer;
``(ii) except as provided in clause (iii), the
establishment of procedures under which discounted prices are
provided to applicable beneficiaries at pharmacies or by mail
order service at the point-of-sale of an applicable drug;
``(iii) in the case where, during the period beginning on
July 1, 2010, and ending on December 31, 2011, it is not
practicable to provide such discounted prices at the point-
of-sale (as described in clause (ii)), the establishment of
procedures to provide such discounted prices as soon as
practicable after the point-of-sale;
``(iv) the establishment of procedures to ensure that, not
later than the applicable number of calendar days after the
dispensing of an applicable drug by a pharmacy or mail order
service, the pharmacy or mail order service is reimbursed for
an amount equal to the difference between--
``(I) the negotiated price of the applicable drug; and
``(II) the discounted price of the applicable drug;
``(v) the establishment of procedures to ensure that the
discounted price for an applicable drug under this section is
applied before any coverage or financial assistance under
other health benefit plans or programs that provide coverage
or financial assistance for the purchase or provision of
prescription drug coverage on behalf of applicable
beneficiaries as the Secretary may specify;
``(vi) the establishment of procedures to implement the
special rule for supplemental benefits under paragraph (2);
and
``(vii) providing a reasonable dispute resolution mechanism
to resolve disagreements between manufacturers, applicable
beneficiaries, and the third party with a contract under
subsection (d)(3).
``(B) Monitoring compliance.--
``(i) In general.--The Secretary shall monitor compliance
by a manufacturer with the terms of an agreement under this
section.
``(ii) Notification.--If a third party with a contract
under subsection (d)(3) determines that the manufacturer is
not in compliance with such agreement, the third party shall
notify the Secretary of such noncompliance for appropriate
enforcement under subsection (e).
``(C) Collection of data from prescription drug plans and
ma-pd plans.--The Secretary may collect appropriate data from
prescription drug plans and MA-PD plans in a timeframe that
allows for discounted prices to be provided for applicable
drugs under this section.
``(2) Special rule for supplemental benefits.--For plan
year 2010 and each subsequent plan year, in the case where an
applicable beneficiary has supplemental benefits with respect
to applicable drugs under the prescription drug plan or MA-PD
plan that the applicable beneficiary is enrolled in, the
applicable beneficiary shall not be provided a discounted
price for an applicable drug under this section until after
such supplemental benefits have been applied with respect to
the applicable drug.
``(d) Administration.--
``(1) In general.--Subject to paragraph (2), the Secretary
shall provide for the implementation of this section,
including the performance of the duties described in
subsection (c)(1).
``(2) Limitation.--
``(A) In general.--Subject to subparagraph (B), in
providing for such implementation, the Secretary shall not
receive or distribute any funds of a manufacturer under the
program.
[[Page H2010]]
``(B) Exception.--The limitation under subparagraph (A)
shall not apply to the Secretary with respect to drugs
dispensed during the period beginning on July 1, 2010, and
ending on December 31, 2010, but only if the Secretary
determines that the exception to such limitation under this
subparagraph is necessary in order for the Secretary to begin
implementation of this section and provide applicable
beneficiaries timely access to discounted prices during such
period.
``(3) Contract with third parties.--The Secretary shall
enter into a contract with 1 or more third parties to
administer the requirements established by the Secretary in
order to carry out this section. At a minimum, the contract
with a third party under the preceding sentence shall require
that the third party--
``(A) receive and transmit information between the
Secretary, manufacturers, and other individuals or entities
the Secretary determines appropriate;
``(B) receive, distribute, or facilitate the distribution
of funds of manufacturers to appropriate individuals or
entities in order to meet the obligations of manufacturers
under agreements under this section;
``(C) provide adequate and timely information to
manufacturers, consistent with the agreement with the
manufacturer under this section, as necessary for the
manufacturer to fulfill its obligations under this section;
and
``(D) permit manufacturers to conduct periodic audits,
directly or through contracts, of the data and information
used by the third party to determine discounts for applicable
drugs of the manufacturer under the program.
``(4) Performance requirements.--The Secretary shall
establish performance requirements for a third party with a
contract under paragraph (3) and safeguards to protect the
independence and integrity of the activities carried out by
the third party under the program under this section.
``(5) Implementation.--The Secretary may implement the
program under this section by program instruction or
otherwise.
``(6) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to the program under this
section.
``(e) Enforcement.--
``(1) Audits.--Each manufacturer with an agreement in
effect under this section shall be subject to periodic audit
by the Secretary.
``(2) Civil money penalty.--
``(A) In general.--The Secretary shall impose a civil money
penalty on a manufacturer that fails to provide applicable
beneficiaries discounts for applicable drugs of the
manufacturer in accordance with such agreement for each such
failure in an amount the Secretary determines is commensurate
with the sum of--
``(i) the amount that the manufacturer would have paid with
respect to such discounts under the agreement, which will
then be used to pay the discounts which the manufacturer had
failed to provide; and
``(ii) 25 percent of such amount.
``(B) Application.--The provisions of section 1128A (other
than subsections (a) and (b)) shall apply to a civil money
penalty under this paragraph in the same manner as such
provisions apply to a penalty or proceeding under section
1128A(a).
``(f) Clarification Regarding Availability of Other Covered
Part D Drugs.--Nothing in this section shall prevent an
applicable beneficiary from purchasing a covered part D drug
that is not an applicable drug (including a generic drug or a
drug that is not on the formulary of the prescription drug
plan or MA-PD plan that the applicable beneficiary is
enrolled in).
``(g) Definitions.--In this section:
``(1) Applicable beneficiary.--The term `applicable
beneficiary' means an individual who, on the date of
dispensing an applicable drug--
``(A) is enrolled in a prescription drug plan or an MA-PD
plan;
``(B) is not enrolled in a qualified retiree prescription
drug plan;
``(C) is not entitled to an income-related subsidy under
section 1860D-14(a);
``(D) is not subject to a reduction in premium subsidy
under section 1839(i); and
``(E) who--
``(i) has reached or exceeded the initial coverage limit
under section 1860D-2(b)(3) during the year; and
``(ii) has not incurred costs for covered part D drugs in
the year equal to the annual out-of-pocket threshold
specified in section 1860D-2(b)(4)(B).
``(2) Applicable drug.--The term `applicable drug' means,
with respect to an applicable beneficiary, a covered part D
drug--
``(A) approved under a new drug application under section
505(b) of the Federal Food, Drug, and Cosmetic Act or, in the
case of a biologic product, licensed under section 351 of the
Public Health Service Act (other than a product licensed
under subsection (k) of such section 351); and
``(B)(i) if the PDP sponsor of the prescription drug plan
or the MA organization offering the MA-PD plan uses a
formulary, which is on the formulary of the prescription drug
plan or MA-PD plan that the applicable beneficiary is
enrolled in;
``(ii) if the PDP sponsor of the prescription drug plan or
the MA organization offering the MA-PD plan does not use a
formulary, for which benefits are available under the
prescription drug plan or MA-PD plan that the applicable
beneficiary is enrolled in; or
``(iii) is provided through an exception or appeal.
``(3) Applicable number of calendar days.--The term
`applicable number of calendar days' means--
``(A) with respect to claims for reimbursement submitted
electronically, 14 days; and
``(B) with respect to claims for reimbursement submitted
otherwise, 30 days.
``(4) Discounted price.--
``(A) In general.--The term `discounted price' means 50
percent of the negotiated price of the applicable drug of a
manufacturer.
``(B) Clarification.--Nothing in this section shall be
construed as affecting the responsibility of an applicable
beneficiary for payment of a dispensing fee for an applicable
drug.
``(C) Special case for certain claims.--In the case where
the entire amount of the negotiated price of an individual
claim for an applicable drug with respect to an applicable
beneficiary does not fall at or above the initial coverage
limit under section 1860D-2(b)(3) and below the annual out-
of-pocket threshold specified in section 1860D-2(b)(4)(B) for
the year, the manufacturer of the applicable drug shall
provide the discounted price under this section on only the
portion of the negotiated price of the applicable drug that
falls at or above such initial coverage limit and below such
annual out-of-pocket threshold.
``(5) Manufacturer.--The term `manufacturer' means any
entity which is engaged in the production, preparation,
propagation, compounding, conversion, or processing of
prescription drug products, either directly or indirectly by
extraction from substances of natural origin, or
independently by means of chemical synthesis, or by a
combination of extraction and chemical synthesis. Such term
does not include a wholesale distributor of drugs or a retail
pharmacy licensed under State law.
``(6) Negotiated price.--The term `negotiated price' has
the meaning given such term in section 423.100 of title 42,
Code of Federal Regulations (as in effect on the date of
enactment of this section), except that such negotiated price
shall not include any dispensing fee for the applicable drug.
``(7) Qualified retiree prescription drug plan.--The term
`qualified retiree prescription drug plan' has the meaning
given such term in section 1860D-22(a)(2).''.
(c) Inclusion in Incurred Costs.--
(1) In general.--Section 1860D-2(b)(4) of the Social
Security Act (42 U.S.C. 1395w-102(b)(4)) is amended--
(A) in subparagraph (C), in the matter preceding clause
(i), by striking ``In applying'' and inserting ``Except as
provided in subparagraph (E), in applying''; and
(B) by adding at the end the following new subparagraph:
``(E) Inclusion of costs of applicable drugs under medicare
coverage gap discount program.--In applying subparagraph (A),
incurred costs shall include the negotiated price (as defined
in paragraph (6) of section 1860D-14A(g)) of an applicable
drug (as defined in paragraph (2) of such section) of a
manufacturer that is furnished to an applicable beneficiary
(as defined in paragraph (1) of such section) under the
Medicare coverage gap discount program under section 1860D-
14A, regardless of whether part of such costs were paid by a
manufacturer under such program.''.
(2) Effective date.--The amendments made by this subsection
shall apply to costs incurred on or after July 1, 2010.
(d) Conforming Amendment Permitting Prescription Drug
Discounts.--
(1) In general.--Section 1128B(b)(3) of the Social Security
Act (42 U.S.C. 1320a-7b(b)(3)) is amended--
(A) by striking ``and'' at the end of subparagraph (G);
(B) in the subparagraph (H) added by section 237(d) of the
Medicare Prescription Drug, Improvement, and Modernization
Act of 2003 (Public Law 108-173; 117 Stat. 2213)--
(i) by moving such subparagraph 2 ems to the left; and
(ii) by striking the period at the end and inserting a
semicolon;
(C) in the subparagraph (H) added by section 431(a) of such
Act (117 Stat. 2287)--
(i) by redesignating such subparagraph as subparagraph (I);
(ii) by moving such subparagraph 2 ems to the left; and
(iii) by striking the period at the end and inserting ``;
and''; and
(D) by adding at the end the following new subparagraph:
``(J) a discount in the price of an applicable drug (as
defined in paragraph (2) of section 1860D-14A(g)) of a
manufacturer that is furnished to an applicable beneficiary
(as defined in paragraph (1) of such section) under the
Medicare coverage gap discount program under section 1860D-
14A.''.
(2) Conforming amendment to definition of best price under
medicaid.--Section 1927(c)(1)(C)(i)(VI) of the Social
Security Act (42 U.S.C. 1396r-8(c)(1)(C)(i)(VI)) is amended
by inserting ``, or any discounts provided by manufacturers
under the Medicare coverage gap discount program under
section 1860D-14A'' before the period at the end.
(3) Effective date.--The amendments made by this subsection
shall apply to drugs dispensed on or after July 1, 2010.
SEC. 3302. IMPROVEMENT IN DETERMINATION OF MEDICARE PART D
LOW-INCOME BENCHMARK PREMIUM.
(a) In General.--Section 1860D-14(b)(2)(B)(iii) of the
Social Security Act (42 U.S.C. 1395w-114(b)(2)(B)(iii)) is
amended by inserting ``, determined without regard to any
reduction in such premium as a result of any beneficiary
rebate under section 1854(b)(1)(C) or bonus payment under
section 1853(n)'' before the period at the end.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to premiums for months beginning on or after
January 1, 2011.
SEC. 3303. VOLUNTARY DE MINIMIS POLICY FOR SUBSIDY ELIGIBLE
INDIVIDUALS UNDER PRESCRIPTION DRUG PLANS AND
MA-PD PLANS.
(a) In General.--Section 1860D-14(a) of the Social Security
Act (42 U.S.C. 1395w-114(a)) is
[[Page H2011]]
amended by adding at the end the following new paragraph:
``(5) Waiver of de minimis premiums.--The Secretary shall,
under procedures established by the Secretary, permit a
prescription drug plan or an MA-PD plan to waive the monthly
beneficiary premium for a subsidy eligible individual if the
amount of such premium is de minimis. If such premium is
waived under the plan, the Secretary shall not reassign
subsidy eligible individuals enrolled in the plan to other
plans based on the fact that the monthly beneficiary premium
under the plan was greater than the low-income benchmark
premium amount.''.
(b) Authorizing the Secretary To Auto-enroll Subsidy
Eligible Individuals in Plans That Waive De Minimis
Premiums.--Section 1860D-1(b)(1) of the Social Security Act
(42 U.S.C. 1395w-101(b)(1)) is amended--
(1) in subparagraph (C), by inserting ``except as provided
in subparagraph (D),'' after ``shall include,''
(2) by adding at the end the following new subparagraph:
``(D) Special rule for plans that waive de minimis
premiums.--The process established under subparagraph (A) may
include, in the case of a part D eligible individual who is a
subsidy eligible individual (as defined in section 1860D-
14(a)(3)) who has failed to enroll in a prescription drug
plan or an MA-PD plan, for the enrollment in a prescription
drug plan or MA-PD plan that has waived the monthly
beneficiary premium for such subsidy eligible individual
under section 1860D-14(a)(5). If there is more than one such
plan available, the Secretary shall enroll such an individual
under the preceding sentence on a random basis among all such
plans in the PDP region. Nothing in the previous sentence
shall prevent such an individual from declining or changing
such enrollment.''.
(c) Effective Date.--The amendments made by this subsection
shall apply to premiums for months, and enrollments for plan
years, beginning on or after January 1, 2011.
SEC. 3304. SPECIAL RULE FOR WIDOWS AND WIDOWERS REGARDING
ELIGIBILITY FOR LOW-INCOME ASSISTANCE.
(a) In General.--Section 1860D-14(a)(3)(B) of the Social
Security Act (42 U.S.C. 1395w-114(a)(3)(B)) is amended by
adding at the end the following new clause:
``(vi) Special rule for widows and widowers.--
Notwithstanding the preceding provisions of this
subparagraph, in the case of an individual whose spouse dies
during the effective period for a determination or
redetermination that has been made under this subparagraph,
such effective period shall be extended through the date that
is 1 year after the date on which the determination or
redetermination would (but for the application of this
clause) otherwise cease to be effective.''.
(b) Effective Date.--The amendment made by subsection (a)
shall take effect on January 1, 2011.
SEC. 3305. IMPROVED INFORMATION FOR SUBSIDY ELIGIBLE
INDIVIDUALS REASSIGNED TO PRESCRIPTION DRUG
PLANS AND MA-PD PLANS.
Section 1860D-14 of the Social Security Act (42 U.S.C.
1395w-114) is amended--
(1) by redesignating subsection (d) as subsection (e); and
(2) by inserting after subsection (c) the following new
subsection:
``(d) Facilitation of Reassignments.--Beginning not later
than January 1, 2011, the Secretary shall, in the case of a
subsidy eligible individual who is enrolled in one
prescription drug plan and is subsequently reassigned by the
Secretary to a new prescription drug plan, provide the
individual, within 30 days of such reassignment, with--
``(1) information on formulary differences between the
individual's former plan and the plan to which the individual
is reassigned with respect to the individual's drug regimens;
and
``(2) a description of the individual's right to request a
coverage determination, exception, or reconsideration under
section 1860D-4(g), bring an appeal under section 1860D-4(h),
or resolve a grievance under section 1860D-4(f).''.
SEC. 3306. FUNDING OUTREACH AND ASSISTANCE FOR LOW-INCOME
PROGRAMS.
(a) Additional Funding for State Health Insurance
Programs.--Subsection (a)(1)(B) of section 119 of the
Medicare Improvements for Patients and Providers Act of 2008
(42 U.S.C. 1395b-3 note) is amended by striking ``(42 U.S.C.
1395w-23(f))'' and all that follows through the period at the
end and inserting ``(42 U.S.C. 1395w-23(f)), to the Centers
for Medicare & Medicaid Services Program Management Account--
``(i) for fiscal year 2009, of $7,500,000; and
``(ii) for the period of fiscal years 2010 through 2012, of
$15,000,000.
Amounts appropriated under this subparagraph shall remain
available until expended.''.
(b) Additional Funding for Area Agencies on Aging.--
Subsection (b)(1)(B) of such section 119 is amended by
striking ``(42 U.S.C. 1395w-23(f))'' and all that follows
through the period at the end and inserting ``(42 U.S.C.
1395w-23(f)), to the Administration on Aging--
``(i) for fiscal year 2009, of $7,500,000; and
``(ii) for the period of fiscal years 2010 through 2012, of
$15,000,000.
Amounts appropriated under this subparagraph shall remain
available until expended.''.
(c) Additional Funding for Aging and Disability Resource
Centers.--Subsection (c)(1)(B) of such section 119 is amended
by striking ``(42 U.S.C. 1395w-23(f))'' and all that follows
through the period at the end and inserting ``(42 U.S.C.
1395w-23(f)), to the Administration on Aging--
``(i) for fiscal year 2009, of $5,000,000; and
``(ii) for the period of fiscal years 2010 through 2012, of
$10,000,000.
Amounts appropriated under this subparagraph shall remain
available until expended.''.
(d) Additional Funding for Contract With the National
Center for Benefits and Outreach Enrollment.--Subsection
(d)(2) of such section 119 is amended by striking ``(42
U.S.C. 1395w-23(f))'' and all that follows through the period
at the end and inserting ``(42 U.S.C. 1395w-23(f)), to the
Administration on Aging--
``(i) for fiscal year 2009, of $5,000,000; and
``(ii) for the period of fiscal years 2010 through 2012, of
$5,000,000.
Amounts appropriated under this subparagraph shall remain
available until expended.''.
(e) Secretarial Authority To Enlist Support in Conducting
Certain Outreach Activities.--Such section 119 is amended by
adding at the end the following new subsection:
``(g) Secretarial Authority To Enlist Support in Conducting
Certain Outreach Activities.--The Secretary may request that
an entity awarded a grant under this section support the
conduct of outreach activities aimed at preventing disease
and promoting wellness. Notwithstanding any other provision
of this section, an entity may use a grant awarded under this
subsection to support the conduct of activities described in
the preceding sentence.''.
SEC. 3307. IMPROVING FORMULARY REQUIREMENTS FOR PRESCRIPTION
DRUG PLANS AND MA-PD PLANS WITH RESPECT TO
CERTAIN CATEGORIES OR CLASSES OF DRUGS.
(a) Improving Formulary Requirements.--Section 1860D-
4(b)(3)(G) of the Social Security Act is amended to read as
follows:
``(G) Required inclusion of drugs in certain categories and
classes.--
``(i) Formulary requirements.--
``(I) In general.--Subject to subclause (II), a PDP sponsor
offering a prescription drug plan shall be required to
include all covered part D drugs in the categories and
classes identified by the Secretary under clause (ii)(I).
``(II) Exceptions.--The Secretary may establish exceptions
that permit a PDP sponsor offering a prescription drug plan
to exclude from its formulary a particular covered part D
drug in a category or class that is otherwise required to be
included in the formulary under subclause (I) (or to
otherwise limit access to such a drug, including through
prior authorization or utilization management).
``(ii) Identification of drugs in certain categories and
classes.--
``(I) In general.--Subject to clause (iv), the Secretary
shall identify, as appropriate, categories and classes of
drugs for which the Secretary determines are of clinical
concern.
``(II) Criteria.--The Secretary shall use criteria
established by the Secretary in making any determination
under subclause (I).
``(iii) Implementation.--The Secretary shall establish the
criteria under clause (ii)(II) and any exceptions under
clause (i)(II) through the promulgation of a regulation which
includes a public notice and comment period.
``(iv) Requirement for certain categories and classes until
criteria established.--Until such time as the Secretary
establishes the criteria under clause (ii)(II) the following
categories and classes of drugs shall be identified under
clause (ii)(I):
``(I) Anticonvulsants.
``(II) Antidepressants.
``(III) Antineoplastics.
``(IV) Antipsychotics.
``(V) Antiretrovirals.
``(VI) Immunosuppressants for the treatment of transplant
rejection.''.
(b) Effective Date.--The amendments made by this section
shall apply to plan year 2011 and subsequent plan years.
SEC. 3308. REDUCING PART D PREMIUM SUBSIDY FOR HIGH-INCOME
BENEFICIARIES.
(a) Income-Related Increase in Part D Premium.--
(1) In general.--Section 1860D-13(a) of the Social Security
Act (42 U.S.C. 1395w-113(a)) is amended by adding at the end
the following new paragraph:
``(7) Increase in base beneficiary premium based on
income.--
``(A) In general.--In the case of an individual whose
modified adjusted gross income exceeds the threshold amount
applicable under paragraph (2) of section 1839(i) (including
application of paragraph (5) of such section) for the
calendar year, the monthly amount of the beneficiary premium
applicable under this section for a month after December 2010
shall be increased by the monthly adjustment amount specified
in subparagraph (B).
``(B) Monthly adjustment amount.--The monthly adjustment
amount specified in this subparagraph for an individual for a
month in a year is equal to the product of--
``(i) the quotient obtained by dividing--
``(I) the applicable percentage determined under paragraph
(3)(C) of section 1839(i) (including application of paragraph
(5) of such section) for the individual for the calendar year
reduced by 25.5 percent; by
``(II) 25.5 percent; and
``(ii) the base beneficiary premium (as computed under
paragraph (2)).
``(C) Modified adjusted gross income.--For purposes of this
paragraph, the term `modified adjusted gross income' has the
meaning given such term in subparagraph (A) of section
1839(i)(4), determined for the taxable year applicable under
subparagraphs (B) and (C) of such section.
``(D) Determination by commissioner of social security.--
The Commissioner of Social Security shall make any
determination necessary to carry out the income-related
increase in the base beneficiary premium under this
paragraph.
``(E) Procedures to assure correct income-related increase
in base beneficiary premium.--
``(i) Disclosure of base beneficiary premium.--Not later
than September 15 of each year beginning with 2010, the
Secretary shall
[[Page H2012]]
disclose to the Commissioner of Social Security the amount of
the base beneficiary premium (as computed under paragraph
(2)) for the purpose of carrying out the income-related
increase in the base beneficiary premium under this paragraph
with respect to the following year.
``(ii) Additional disclosure.--Not later than October 15 of
each year beginning with 2010, the Secretary shall disclose
to the Commissioner of Social Security the following
information for the purpose of carrying out the income-
related increase in the base beneficiary premium under this
paragraph with respect to the following year:
``(I) The modified adjusted gross income threshold
applicable under paragraph (2) of section 1839(i) (including
application of paragraph (5) of such section).
``(II) The applicable percentage determined under paragraph
(3)(C) of section 1839(i) (including application of paragraph
(5) of such section).
``(III) The monthly adjustment amount specified in
subparagraph (B).
``(IV) Any other information the Commissioner of Social
Security determines necessary to carry out the income-related
increase in the base beneficiary premium under this
paragraph.
``(F) Rule of construction.--The formula used to determine
the monthly adjustment amount specified under subparagraph
(B) shall only be used for the purpose of determining such
monthly adjustment amount under such subparagraph.''.
(2) Collection of monthly adjustment amount.--Section
1860D-13(c) of the Social Security Act (42 U.S.C. 1395w-
113(c)) is amended--
(A) in paragraph (1), by striking ``(2) and (3)'' and
inserting ``(2), (3), and (4)''; and
(B) by adding at the end the following new paragraph:
``(4) Collection of monthly adjustment amount.--
``(A) In general.--Notwithstanding any provision of this
subsection or section 1854(d)(2), subject to subparagraph
(B), the amount of the income-related increase in the base
beneficiary premium for an individual for a month (as
determined under subsection (a)(7)) shall be paid through
withholding from benefit payments in the manner provided
under section 1840.
``(B) Agreements.--In the case where the monthly benefit
payments of an individual that are withheld under
subparagraph (A) are insufficient to pay the amount described
in such subparagraph, the Commissioner of Social Security
shall enter into agreements with the Secretary, the Director
of the Office of Personnel Management, and the Railroad
Retirement Board as necessary in order to allow other
agencies to collect the amount described in subparagraph (A)
that was not withheld under such subparagraph.''.
(b) Conforming Amendments.--
(1) Medicare.--Section 1860D-13(a)(1) of the Social
Security Act (42 U.S.C. 1395w-113(a)(1)) is amended--
(A) by redesignating subparagraph (F) as subparagraph (G);
(B) in subparagraph (G), as redesignated by subparagraph
(A), by striking ``(D) and (E)'' and inserting ``(D), (E),
and (F)''; and
(C) by inserting after subparagraph (E) the following new
subparagraph:
``(F) Increase based on income.--The monthly beneficiary
premium shall be increased pursuant to paragraph (7).''.
(2) Internal revenue code.--Section 6103(l)(20) of the
Internal Revenue Code of 1986 (relating to disclosure of
return information to carry out Medicare part B premium
subsidy adjustment) is amended--
(A) in the heading, by inserting ``and part d base
beneficiary premium increase'' after ``part b premium subsidy
adjustment'';
(B) in subparagraph (A)--
(i) in the matter preceding clause (i), by inserting ``or
increase under section 1860D-13(a)(7)'' after ``1839(i)'';
and
(ii) in clause (vii), by inserting after ``subsection (i)
of such section'' the following: ``or increase under section
1860D-13(a)(7) of such Act''; and
(C) in subparagraph (B)--
(i) by striking ``Return information'' and inserting the
following:
``(i) In general.--Return information'';
(ii) by inserting ``or increase under such section 1860D-
13(a)(7)'' before the period at the end;
(iii) as amended by clause (i), by inserting ``or for the
purpose of resolving taxpayer appeals with respect to any
such premium adjustment or increase'' before the period at
the end; and
(iv) by adding at the end the following new clause:
``(ii) Disclosure to other agencies.--Officers, employees,
and contractors of the Social Security Administration may
disclose--
``(I) the taxpayer identity information and the amount of
the premium subsidy adjustment or premium increase with
respect to a taxpayer described in subparagraph (A) to
officers, employees, and contractors of the Centers for
Medicare and Medicaid Services, to the extent that such
disclosure is necessary for the collection of the premium
subsidy amount or the increased premium amount,
``(II) the taxpayer identity information and the amount of
the premium subsidy adjustment or the increased premium
amount with respect to a taxpayer described in subparagraph
(A) to officers and employees of the Office of Personnel
Management and the Railroad Retirement Board, to the extent
that such disclosure is necessary for the collection of the
premium subsidy amount or the increased premium amount,
``(III) return information with respect to a taxpayer
described in subparagraph (A) to officers and employees of
the Department of Health and Human Services to the extent
necessary to resolve administrative appeals of such premium
subsidy adjustment or increased premium, and
``(IV) return information with respect to a taxpayer
described in subparagraph (A) to officers and employees of
the Department of Justice for use in judicial proceedings to
the extent necessary to carry out the purposes described in
clause (i).''.
SEC. 3309. ELIMINATION OF COST SHARING FOR CERTAIN DUAL
ELIGIBLE INDIVIDUALS.
Section 1860D-14(a)(1)(D)(i) of the Social Security Act (42
U.S.C. 1395w-114(a)(1)(D)(i)) is amended by inserting ``or,
effective on a date specified by the Secretary (but in no
case earlier than January 1, 2012), who would be such an
institutionalized individual or couple, if the full-benefit
dual eligible individual were not receiving services under a
home and community-based waiver authorized for a State under
section 1115 or subsection (c) or (d) of section 1915 or
under a State plan amendment under subsection (i) of such
section or services provided through enrollment in a medicaid
managed care organization with a contract under section
1903(m) or under section 1932'' after ``1902(q)(1)(B))''.
SEC. 3310. REDUCING WASTEFUL DISPENSING OF OUTPATIENT
PRESCRIPTION DRUGS IN LONG-TERM CARE FACILITIES
UNDER PRESCRIPTION DRUG PLANS AND MA-PD PLANS.
(a) In General.--Section 1860D-4(c) of the Social Security
Act (42 U.S.C. 1395w-104(c)) is amended by adding at the end
the following new paragraph:
``(3) Reducing wasteful dispensing of outpatient
prescription drugs in long-term care facilities.--The
Secretary shall require PDP sponsors of prescription drug
plans to utilize specific, uniform dispensing techniques, as
determined by the Secretary, in consultation with relevant
stakeholders (including representatives of nursing
facilities, residents of nursing facilities, pharmacists, the
pharmacy industry (including retail and long-term care
pharmacy), prescription drug plans, MA-PD plans, and any
other stakeholders the Secretary determines appropriate),
such as weekly, daily, or automated dose dispensing, when
dispensing covered part D drugs to enrollees who reside in a
long-term care facility in order to reduce waste associated
with 30-day fills.''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to plan years beginning on or after January 1,
2012.
SEC. 3311. IMPROVED MEDICARE PRESCRIPTION DRUG PLAN AND MA-PD
PLAN COMPLAINT SYSTEM.
(a) In General.--The Secretary shall develop and maintain a
complaint system, that is widely known and easy to use, to
collect and maintain information on MA-PD plan and
prescription drug plan complaints that are received
(including by telephone, letter, e-mail, or any other means)
by the Secretary (including by a regional office of the
Department of Health and Human Services, the Medicare
Beneficiary Ombudsman, a subcontractor, a carrier, a fiscal
intermediary, and a Medicare administrative contractor under
section 1874A of the Social Security Act (42 U.S.C. 1395kk))
through the date on which the complaint is resolved. The
system shall be able to report and initiate appropriate
interventions and monitoring based on substantial complaints
and to guide quality improvement.
(b) Model Electronic Complaint Form.--The Secretary shall
develop a model electronic complaint form to be used for
reporting plan complaints under the system. Such form shall
be prominently displayed on the front page of the
Medicare.gov Internet website and on the Internet website of
the Medicare Beneficiary Ombudsman.
(c) Annual Reports by the Secretary.--The Secretary shall
submit to Congress annual reports on the system. Such reports
shall include an analysis of the number and types of
complaints reported in the system, geographic variations in
such complaints, the timeliness of agency or plan responses
to such complaints, and the resolution of such complaints.
(d) Definitions.--In this section:
(1) MA-PD plan.--The term ``MA-PD plan'' has the meaning
given such term in section 1860D-41(a)(9) of such Act (42
U.S.C. 1395w-151(a)(9)).
(2) Prescription drug plan.--The term ``prescription drug
plan'' has the meaning given such term in section 1860D-
41(a)(14) of such Act (42 U.S.C. 1395w-151(a)(14)).
(3) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(4) System.--The term ``system'' means the plan complaint
system developed and maintained under subsection (a).
SEC. 3312. UNIFORM EXCEPTIONS AND APPEALS PROCESS FOR
PRESCRIPTION DRUG PLANS AND MA-PD PLANS.
(a) In General.--Section 1860D-4(b)(3) of the Social
Security Act (42 U.S.C. 1395w-104(b)(3)) is amended by adding
at the end the following new subparagraph:
``(H) Use of single, uniform exceptions and appeals
process.--Notwithstanding any other provision of this part,
each PDP sponsor of a prescription drug plan shall--
``(i) use a single, uniform exceptions and appeals process
(including, to the extent the Secretary determines feasible,
a single, uniform model form for use under such process) with
respect to the determination of prescription drug coverage
for an enrollee under the plan; and
``(ii) provide instant access to such process by enrollees
through a toll-free telephone number and an Internet
website.''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to exceptions and appeals on or after January 1,
2012.
SEC. 3313. OFFICE OF THE INSPECTOR GENERAL STUDIES AND
REPORTS.
(a) Study and Annual Report on Part D Formularies'
Inclusion of Drugs Commonly Used by Dual Eligibles.--
[[Page H2013]]
(1) Study.--The Inspector General of the Department of
Health and Human Services shall conduct a study of the extent
to which formularies used by prescription drug plans and MA-
PD plans under part D include drugs commonly used by full-
benefit dual eligible individuals (as defined in section
1935(c)(6) of the Social Security Act (42 U.S.C. 1396u-
5(c)(6))).
(2) Annual reports.--Not later than July 1 of each year
(beginning with 2011), the Inspector General shall submit to
Congress a report on the study conducted under paragraph (1),
together with such recommendations as the Inspector General
determines appropriate.
(b) Study and Report on Prescription Drug Prices Under
Medicare Part D and Medicaid.--
(1) Study.--
(A) In general.--The Inspector General of the Department of
Health and Human Services shall conduct a study on prices for
covered part D drugs under the Medicare prescription drug
program under part D of title XVIII of the Social Security
Act and for covered outpatient drugs under title XIX. Such
study shall include the following:
(i) A comparison, with respect to the 200 most frequently
dispensed covered part D drugs under such program and covered
outpatient drugs under such title (as determined by the
Inspector General based on volume and expenditures), of--
(I) the prices paid for covered part D drugs by PDP
sponsors of prescription drug plans and Medicare Advantage
organizations offering MA-PD plans; and
(II) the prices paid for covered outpatient drugs by a
State plan under title XIX.
(ii) An assessment of--
(I) the financial impact of any discrepancies in such
prices on the Federal Government; and
(II) the financial impact of any such discrepancies on
enrollees under part D or individuals eligible for medical
assistance under a State plan under title XIX.
(B) Price.--For purposes of subparagraph (A), the price of
a covered part D drug or a covered outpatient drug shall
include any rebate or discount under such program or such
title, respectively, including any negotiated price
concession described in section 1860D-2(d)(1)(B) of the
Social Security Act (42 U.S.C. 1395w-102(d)(1)(B)) or rebate
under an agreement under section 1927 of the Social Security
Act (42 U.S.C. 1396r-8).
(C) Authority to collect any necessary information.--
Notwithstanding any other provision of law, the Inspector
General of the Department of Health and Human Services shall
be able to collect any information related to the prices of
covered part D drugs under such program and covered
outpatient drugs under such title XIX necessary to carry out
the comparison under subparagraph (A).
(2) Report.--
(A) In general.--Not later than October 1, 2011, subject to
subparagraph (B), the Inspector General shall submit to
Congress a report containing the results of the study
conducted under paragraph (1), together with recommendations
for such legislation and administrative action as the
Inspector General determines appropriate.
(B) Limitation on information contained in report.--The
report submitted under subparagraph (A) shall not include any
information that the Inspector General determines is
proprietary or is likely to negatively impact the ability of
a PDP sponsor or a State plan under title XIX to negotiate
prices for covered part D drugs or covered outpatient drugs,
respectively.
(3) Definitions.--In this section:
(A) Covered part d drug.--The term ``covered part D drug''
has the meaning given such term in section 1860D-2(e) of the
Social Security Act (42 U.S.C. 1395w-102(e)).
(B) Covered outpatient drug.--The term ``covered outpatient
drug'' has the meaning given such term in section 1927(k) of
such Act (42 U.S.C. 1396r(k)).
(C) MA-PD plan.--The term ``MA-PD plan'' has the meaning
given such term in section 1860D-41(a)(9) of such Act (42
U.S.C. 1395w-151(a)(9)).
(D) Medicare advantage organization.--The term ``Medicare
Advantage organization'' has the meaning given such term in
section 1859(a)(1) of such Act (42 U.S.C. 1395w-28)(a)(1)).
(E) PDP sponsor.--The term ``PDP sponsor'' has the meaning
given such term in section 1860D-41(a)(13) of such Act (42
U.S.C. 1395w-151(a)(13)).
(F) Prescription drug plan.--The term ``prescription drug
plan'' has the meaning given such term in section 1860D-
41(a)(14) of such Act (42 U.S.C. 1395w-151(a)(14)).
SEC. 3314. INCLUDING COSTS INCURRED BY AIDS DRUG ASSISTANCE
PROGRAMS AND INDIAN HEALTH SERVICE IN PROVIDING
PRESCRIPTION DRUGS TOWARD THE ANNUAL OUT-OF-
POCKET THRESHOLD UNDER PART D.
(a) In General.--Section 1860D-2(b)(4)(C) of the Social
Security Act (42 U.S.C. 1395w-102(b)(4)(C)) is amended--
(1) in clause (i), by striking ``and'' at the end;
(2) in clause (ii)--
(A) by striking ``such costs shall be treated as incurred
only if'' and inserting ``subject to clause (iii), such costs
shall be treated as incurred only if'';
(B) by striking ``, under section 1860D-14, or under a
State Pharmaceutical Assistance Program''; and
(C) by striking the period at the end and inserting ``;
and''; and
(3) by inserting after clause (ii) the following new
clause:
``(iii) such costs shall be treated as incurred and shall
not be considered to be reimbursed under clause (ii) if such
costs are borne or paid--
``(I) under section 1860D-14;
``(II) under a State Pharmaceutical Assistance Program;
``(III) by the Indian Health Service, an Indian tribe or
tribal organization, or an urban Indian organization (as
defined in section 4 of the Indian Health Care Improvement
Act); or
``(IV) under an AIDS Drug Assistance Program under part B
of title XXVI of the Public Health Service Act.''.
(b) Effective Date.--The amendments made by subsection (a)
shall apply to costs incurred on or after January 1, 2011.
SEC. 3315. IMMEDIATE REDUCTION IN COVERAGE GAP IN 2010.
Section 1860D-2(b) of the Social Security Act (42 U.S.C.
1395w-102(b)) is amended--
(1) in paragraph (3)(A), by striking ``paragraph (4)'' and
inserting ``paragraphs (4) and (7)''; and
(2) by adding at the end the following new paragraph:
``(7) Increase in initial coverage limit in 2010.--
``(A) In general.--For the plan year beginning on January
1, 2010, the initial coverage limit described in paragraph
(3)(B) otherwise applicable shall be increased by $500.
``(B) Application.--In applying subparagraph (A)--
``(i) except as otherwise provided in this subparagraph,
there shall be no change in the premiums, bids, or any other
parameters under this part or part C;
``(ii) costs that would be treated as incurred costs for
purposes of applying paragraph (4) but for the application of
subparagraph (A) shall continue to be treated as incurred
costs;
``(iii) the Secretary shall establish procedures, which may
include a reconciliation process, to fully reimburse PDP
sponsors with respect to prescription drug plans and MA
organizations with respect to MA-PD plans for the reduction
in beneficiary cost sharing associated with the application
of subparagraph (A);
``(iv) the Secretary shall develop an estimate of the
additional increased costs attributable to the application of
this paragraph for increased drug utilization and financing
and administrative costs and shall use such estimate to
adjust payments to PDP sponsors with respect to prescription
drug plans under this part and MA organizations with respect
to MA-PD plans under part C; and
``(v) the Secretary shall establish procedures for
retroactive reimbursement of part D eligible individuals who
are covered under such a plan for costs which are incurred
before the date of initial implementation of subparagraph (A)
and which would be reimbursed under such a plan if such
implementation occurred as of January 1, 2010.
``(C) No effect on subsequent years.--The increase under
subparagraph (A) shall only apply with respect to the plan
year beginning on January 1, 2010, and the initial coverage
limit for plan years beginning on or after January 1, 2011,
shall be determined as if subparagraph (A) had never
applied.''.
Subtitle E--Ensuring Medicare Sustainability
SEC. 3401. REVISION OF CERTAIN MARKET BASKET UPDATES AND
INCORPORATION OF PRODUCTIVITY IMPROVEMENTS INTO
MARKET BASKET UPDATES THAT DO NOT ALREADY
INCORPORATE SUCH IMPROVEMENTS.
(a) Inpatient Acute Hospitals.--Section 1886(b)(3)(B) of
the Social Security Act (42 U.S.C. 1395ww(b)(3)(B)), as
amended by section 3001(a)(3), is further amended--
(1) in clause (i)(XX), by striking ``clause (viii)'' and
inserting ``clauses (viii), (ix), (xi), and (xii)'';
(2) in the first sentence of clause (viii), by inserting
``of such applicable percentage increase (determined without
regard to clause (ix), (xi), or (xii))'' after ``one-
quarter'';
(3) in the first sentence of clause (ix)(I), by inserting
``(determined without regard to clause (viii), (xi), or
(xii))'' after ``clause (i)'' the second time it appears; and
(4) by adding at the end the following new clauses:
``(xi)(I) For 2012 and each subsequent fiscal year, after
determining the applicable percentage increase described in
clause (i) and after application of clauses (viii) and (ix),
such percentage increase shall be reduced by the productivity
adjustment described in subclause (II).
``(II) The productivity adjustment described in this
subclause, with respect to a percentage, factor, or update
for a fiscal year, year, cost reporting period, or other
annual period, is a productivity adjustment equal to the 10-
year moving average of changes in annual economy-wide private
nonfarm business multi-factor productivity (as projected by
the Secretary for the 10-year period ending with the
applicable fiscal year, year, cost reporting period, or other
annual period).
``(III) The application of subclause (I) may result in the
applicable percentage increase described in clause (i) being
less than 0.0 for a fiscal year, and may result in payment
rates under this section for a fiscal year being less than
such payment rates for the preceding fiscal year.
``(xii) After determining the applicable percentage
increase described in clause (i), and after application of
clauses (viii), (ix), and (xi), the Secretary shall reduce
such applicable percentage increase--
``(I) for each of fiscal years 2010 and 2011, by 0.25
percentage point; and
``(II) subject to clause (xiii), for each of fiscal years
2012 through 2019, by 0.2 percentage point.
The application of this clause may result in the applicable
percentage increase described in clause (i) being less than
0.0 for a fiscal year, and may result in payment rates under
this section for a fiscal year being less than such payment
rates for the preceding fiscal year.
[[Page H2014]]
``(xiii) Clause (xii) shall be applied with respect to any
of fiscal years 2014 through 2019 by substituting `0.0
percentage points' for `0.2 percentage point', if for such
fiscal year--
``(I) the excess (if any) of--
``(aa) the total percentage of the non-elderly insured
population for the preceding fiscal year (based on the most
recent estimates available from the Director of the
Congressional Budget Office before a vote in either House on
the Patient Protection and Affordable Care Act that, if
determined in the affirmative, would clear such Act for
enrollment); over
``(bb) the total percentage of the non-elderly insured
population for such preceding fiscal year (as estimated by
the Secretary); exceeds
``(II) 5 percentage points.''.
(b) Skilled Nursing Facilities.--Section 1888(e)(5)(B) of
the Social Security Act (42 U.S.C. 1395yy(e)(5)(B)) is
amended--
(1) by striking ``percentage.--The term'' and inserting
``percentage.--
``(i) In general.--Subject to clause (ii), the term''; and
(2) by adding at the end the following new clause:
``(ii) Adjustment.--For fiscal year 2012 and each
subsequent fiscal year, after determining the percentage
described in clause (i), the Secretary shall reduce such
percentage by the productivity adjustment described in
section 1886(b)(3)(B)(xi)(II). The application of the
preceding sentence may result in such percentage being less
than 0.0 for a fiscal year, and may result in payment rates
under this subsection for a fiscal year being less than such
payment rates for the preceding fiscal year.''.
(c) Long-term Care Hospitals.--Section 1886(m) of the
Social Security Act (42 U.S.C. 1395ww(m)) is amended by
adding at the end the following new paragraphs:
``(3) Implementation for rate year 2010 and subsequent
years.--
``(A) In general.--In implementing the system described in
paragraph (1) for rate year 2010 and each subsequent rate
year, any annual update to a standard Federal rate for
discharges for the hospital during the rate year, shall be
reduced--
``(i) for rate year 2012 and each subsequent rate year, by
the productivity adjustment described in section
1886(b)(3)(B)(xi)(II); and
``(ii) for each of rate years 2010 through 2019, by the
other adjustment described in paragraph (4).
``(B) Special rule.--The application of this paragraph may
result in such annual update being less than 0.0 for a rate
year, and may result in payment rates under the system
described in paragraph (1) for a rate year being less than
such payment rates for the preceding rate year.
``(4) Other adjustment.--
``(A) In general.--For purposes of paragraph (3)(A)(ii),
the other adjustment described in this paragraph is--
``(i) for each of rate years 2010 and 2011, 0.25 percentage
point; and
``(ii) subject to subparagraph (B), for each of rate years
2012 through 2019, 0.2 percentage point.
``(B) Reduction of other adjustment.--Subparagraph (A)(ii)
shall be applied with respect to any of rate years 2014
through 2019 by substituting `0.0 percentage points' for `0.2
percentage point', if for such rate year--
``(i) the excess (if any) of--
``(I) the total percentage of the non-elderly insured
population for the preceding rate year (based on the most
recent estimates available from the Director of the
Congressional Budget Office before a vote in either House on
the Patient Protection and Affordable Care Act that, if
determined in the affirmative, would clear such Act for
enrollment); over
``(II) the total percentage of the non-elderly insured
population for such preceding rate year (as estimated by the
Secretary); exceeds
``(ii) 5 percentage points.''.
(d) Inpatient Rehabilitation Facilities.--Section
1886(j)(3) of the Social Security Act (42 U.S.C.
1395ww(j)(3)) is amended--
(1) in subparagraph (C)--
(A) by striking ``factor.--For purposes'' and inserting
``factor.--
``(i) In general.--For purposes'';
(B) by inserting ``subject to clause (ii)'' before the
period at the end of the first sentence of clause (i), as
added by paragraph (1); and
(C) by adding at the end the following new clause:
``(ii) Productivity and other adjustment.--After
establishing the increase factor described in clause (i) for
a fiscal year, the Secretary shall reduce such increase
factor--
``(I) for fiscal year 2012 and each subsequent fiscal year,
by the productivity adjustment described in section
1886(b)(3)(B)(xi)(II); and
``(II) for each of fiscal years 2010 through 2019, by the
other adjustment described in subparagraph (D).
The application of this clause may result in the increase
factor under this subparagraph being less than 0.0 for a
fiscal year, and may result in payment rates under this
subsection for a fiscal year being less than such payment
rates for the preceding fiscal year.''; and
(2) by adding at the end the following new subparagraph:
``(D) Other adjustment.--
``(i) In general.--For purposes of subparagraph
(C)(ii)(II), the other adjustment described in this
subparagraph is--
``(I) for each of fiscal years 2010 and 2011, 0.25
percentage point; and
``(II) subject to clause (ii), for each of fiscal years
2012 through 2019, 0.2 percentage point.
``(ii) Reduction of other adjustment.--Clause (i)(II) shall
be applied with respect to any of fiscal years 2014 through
2019 by substituting `0.0 percentage points' for `0.2
percentage point', if for such fiscal year--
``(I) the excess (if any) of--
``(aa) the total percentage of the non-elderly insured
population for the preceding fiscal year (based on the most
recent estimates available from the Director of the
Congressional Budget Office before a vote in either House on
the Patient Protection and Affordable Care Act that, if
determined in the affirmative, would clear such Act for
enrollment); over
``(bb) the total percentage of the non-elderly insured
population for such preceding fiscal year (as estimated by
the Secretary); exceeds
``(II) 5 percentage points.''.
(e) Home Health Agencies.--Section 1895(b)(3)(B) of the
Social Security Act (42 U.S.C. 1395fff(b)(3)(B)) is amended--
(1) in clause (ii)(V), by striking ``clause (v)'' and
inserting ``clauses (v) and (vi)''; and
(2) by adding at the end the following new clause:
``(vi) Adjustments.--After determining the home health
market basket percentage increase under clause (iii), and
after application of clause (v), the Secretary shall reduce
such percentage--
``(I) for 2015 and each subsequent year, by the
productivity adjustment described in section
1886(b)(3)(B)(xi)(II); and
``(II) for each of 2011 and 2012, by 1 percentage point.
The application of this clause may result in the home health
market basket percentage increase under clause (iii) being
less than 0.0 for a year, and may result in payment rates
under the system under this subsection for a year being less
than such payment rates for the preceding year.''.
(f) Psychiatric Hospitals.--Section 1886 of the Social
Security Act, as amended by sections 3001, 3008, 3025, and
3133, is amended by adding at the end the following new
subsection:
``(s) Prospective Payment for Psychiatric Hospitals.--
``(1) Reference to establishment and implementation of
system.--For provisions related to the establishment and
implementation of a prospective payment system for payments
under this title for inpatient hospital services furnished by
psychiatric hospitals (as described in clause (i) of
subsection (d)(1)(B)) and psychiatric units (as described in
the matter following clause (v) of such subsection), see
section 124 of the Medicare, Medicaid, and SCHIP Balanced
Budget Refinement Act of 1999.
``(2) Implementation for rate year beginning in 2010 and
subsequent rate years.--
``(A) In general.--In implementing the system described in
paragraph (1) for the rate year beginning in 2010 and any
subsequent rate year, any update to a base rate for days
during the rate year for a psychiatric hospital or unit,
respectively, shall be reduced--
``(i) for the rate year beginning in 2012 and each
subsequent rate year, by the productivity adjustment
described in section 1886(b)(3)(B)(xi)(II); and
``(ii) for each of the rate years beginning in 2010 through
2019, by the other adjustment described in paragraph (3).
``(B) Special rule.--The application of this paragraph may
result in such update being less than 0.0 for a rate year,
and may result in payment rates under the system described in
paragraph (1) for a rate year being less than such payment
rates for the preceding rate year.
``(3) Other adjustment.--
``(A) In general.--For purposes of paragraph (2)(A)(ii),
the other adjustment described in this paragraph is--
``(i) for each of the rate years beginning in 2010 and
2011, 0.25 percentage point; and
``(ii) subject to subparagraph (B), for each of the rate
years beginning in 2012 through 2019, 0.2 percentage point.
``(B) Reduction of other adjustment.--Subparagraph (A)(ii)
shall be applied with respect to any of rate years 2014
through 2019 by substituting `0.0 percentage points' for `0.2
percentage point', if for such rate year--
``(i) the excess (if any) of--
``(I) the total percentage of the non-elderly insured
population for the preceding rate year (based on the most
recent estimates available from the Director of the
Congressional Budget Office before a vote in either House on
the Patient Protection and Affordable Care Act that, if
determined in the affirmative, would clear such Act for
enrollment); over
``(II) the total percentage of the non-elderly insured
population for such preceding rate year (as estimated by the
Secretary); exceeds
``(ii) 5 percentage points.''.
(g) Hospice Care.--Section 1814(i)(1)(C) of the Social
Security Act (42 U.S.C. 1395f(i)(1)(C)), as amended by
section 3132, is amended by adding at the end the following
new clauses:
``(iv) After determining the market basket percentage
increase under clause (ii)(VII) or (iii), as applicable, with
respect to fiscal year 2013 and each subsequent fiscal year,
the Secretary shall reduce such percentage--
``(I) for 2013 and each subsequent fiscal year, by the
productivity adjustment described in section
1886(b)(3)(B)(xi)(II); and
``(II) subject to clause (v), for each of fiscal years 2013
through 2019, by 0.5 percentage point.
The application of this clause may result in the market
basket percentage increase under clause (ii)(VII) or (iii),
as applicable, being less than 0.0 for a fiscal year, and may
result in payment rates under this subsection for a fiscal
year being less than such payment rates for the preceding
fiscal year.
``(v) Clause (iv)(II) shall be applied with respect to any
of fiscal years 2014 through 2019 by substituting `0.0
percentage points' for `0.5 percentage point', if for such
fiscal year--
``(I) the excess (if any) of--
``(aa) the total percentage of the non-elderly insured
population for the preceding fiscal year
[[Page H2015]]
(based on the most recent estimates available from the
Director of the Congressional Budget Office before a vote in
either House on the Patient Protection and Affordable Care
Act that, if determined in the affirmative, would clear such
Act for enrollment); over
``(bb) the total percentage of the non-elderly insured
population for such preceding fiscal year (as estimated by
the Secretary); exceeds
``(II) 5 percentage points.''.
(h) Dialysis.--Section 1881(b)(14)(F) of the Social
Security Act (42 U.S.C. 1395rr(b)(14)(F)) is amended--
(1) in clause (i)--
(A) by inserting ``(I)'' after ``(F)(i)''
(B) in subclause (I), as inserted by subparagraph (A)--
(i) by striking ``clause (ii)'' and inserting ``subclause
(II) and clause (ii)''; and
(ii) by striking ``minus 1.0 percentage point''; and
(C) by adding at the end the following new subclause:
``(II) For 2012 and each subsequent year, after determining
the increase factor described in subclause (I), the Secretary
shall reduce such increase factor by the productivity
adjustment described in section 1886(b)(3)(B)(xi)(II). The
application of the preceding sentence may result in such
increase factor being less than 0.0 for a year, and may
result in payment rates under the payment system under this
paragraph for a year being less than such payment rates for
the preceding year.''; and
(2) in clause (ii)(II)--
(A) by striking ``The'' and inserting ``Subject to clause
(i)(II), the''; and
(B) by striking ``clause (i) minus 1.0 percentage point''
and inserting ``clause (i)(I)''.
(i) Outpatient Hospitals.--Section 1833(t)(3) of the Social
Security Act (42 U.S.C. 1395l(t)(3)) is amended--
(1) in subparagraph (C)(iv), by inserting ``and
subparagraph (F) of this paragraph'' after ``(17)''; and
(2) by adding at the end the following new subparagraphs:
``(F) Productivity and other adjustment.--After determining
the OPD fee schedule increase factor under subparagraph
(C)(iv), the Secretary shall reduce such increase factor--
``(i) for 2012 and subsequent years, by the productivity
adjustment described in section 1886(b)(3)(B)(xi)(II); and
``(ii) for each of 2010 through 2019, by the adjustment
described in subparagraph (G).
The application of this subparagraph may result in the
increase factor under subparagraph (C)(iv) being less than
0.0 for a year, and may result in payment rates under the
payment system under this subsection for a year being less
than such payment rates for the preceding year.
``(G) Other adjustment.--
``(i) Adjustment.--For purposes of subparagraph (F)(ii),
the adjustment described in this subparagraph is--
``(I) for each of 2010 and 2011, 0.25 percentage point; and
``(II) subject to clause (ii), for each of 2012 through
2019, 0.2 percentage point.
``(ii) Reduction of other adjustment.--Clause (i)(II) shall
be applied with respect to any of 2014 through 2019 by
substituting `0.0 percentage points' for `0.2 percentage
point', if for such year--
``(I) the excess (if any) of--
``(aa) the total percentage of the non-elderly insured
population for the preceding year (based on the most recent
estimates available from the Director of the Congressional
Budget Office before a vote in either House on the Patient
Protection and Affordable Care Act that, if determined in the
affirmative, would clear such Act for enrollment); over
``(bb) the total percentage of the non-elderly insured
population for such preceding year (as estimated by the
Secretary); exceeds
``(II) 5 percentage points.''.
(j) Ambulance Services.--Section 1834(l)(3) of the Social
Security Act (42 U.S.C. 1395m(l)(3)) is amended--
(1) in subparagraph (A), by striking ``and'' at the end;
(2) in subparagraph (B)--
(A) by inserting ``, subject to subparagraph (C) and the
succeeding sentence of this paragraph,'' after ``increased'';
and
(B) by striking the period at the end and inserting ``;
and'';
(3) by adding at the end the following new subparagraph:
``(C) for 2011 and each subsequent year, after determining
the percentage increase under subparagraph (B) for the year,
reduce such percentage increase by the productivity
adjustment described in section 1886(b)(3)(B)(xi)(II).''; and
(4) by adding at the end the following flush sentence:
``The application of subparagraph (C) may result in the
percentage increase under subparagraph (B) being less than
0.0 for a year, and may result in payment rates under the fee
schedule under this subsection for a year being less than
such payment rates for the preceding year.''.
(k) Ambulatory Surgical Center Services.--Section
1833(i)(2)(D) of the Social Security Act (42 U.S.C.
1395l(i)(2)(D)) is amended--
(1) by redesignating clause (v) as clause (vi); and
(2) by inserting after clause (iv) the following new
clause:
``(v) In implementing the system described in clause (i)
for 2011 and each subsequent year, any annual update under
such system for the year, after application of clause (iv),
shall be reduced by the productivity adjustment described in
section 1886(b)(3)(B)(xi)(II). The application of the
preceding sentence may result in such update being less than
0.0 for a year, and may result in payment rates under the
system described in clause (i) for a year being less than
such payment rates for the preceding year.''.
(l) Laboratory Services.--Section 1833(h)(2)(A) of the
Social Security Act (42 U.S.C. 1395l(h)(2)(A)) is amended--
(1) in clause (i)--
(A) by inserting ``, subject to clause (iv),'' after
``year) by''; and
(B) by striking ``through 2013'' and inserting ``and
2010''; and
(2) by adding at the end the following new clause:
``(iv) After determining the adjustment to the fee
schedules under clause (i), the Secretary shall reduce such
adjustment--
``(I) for 2011 and each subsequent year, by the
productivity adjustment described in section
1886(b)(3)(B)(xi)(II); and
``(II) for each of 2011 through 2015, by 1.75 percentage
points.
Subclause (I) shall not apply in a year where the adjustment
to the fee schedules determined under clause (i) is 0.0 or a
percentage decrease for a year. The application of the
productivity adjustment under subclause (I) shall not result
in an adjustment to the fee schedules under clause (i) being
less than 0.0 for a year. The application of subclause (II)
may result in an adjustment to the fee schedules under clause
(i) being less than 0.0 for a year, and may result in payment
rates for a year being less than such payment rates for the
preceding year.''.
(m) Certain Durable Medical Equipment.--Section 1834(a)(14)
of the Social Security Act (42 U.S.C. 1395m(a)(14)) is
amended--
(1) in subparagraph (K)--
(A) by striking ``2011, 2012, and 2013,''; and
(B) by inserting ``and'' after the semicolon at the end;
(2) by striking subparagraphs (L) and (M) and inserting the
following new subparagraph:
``(L) for 2011 and each subsequent year--
``(i) the percentage increase in the consumer price index
for all urban consumers (United States city average) for the
12-month period ending with June of the previous year,
reduced by--
``(ii) the productivity adjustment described in section
1886(b)(3)(B)(xi)(II).''; and
(3) by adding at the end the following flush sentence:
``The application of subparagraph (L)(ii) may result in the
covered item update under this paragraph being less than 0.0
for a year, and may result in payment rates under this
subsection for a year being less than such payment rates for
the preceding year.''.
(n) Prosthetic Devices, Orthotics, and Prosthetics.--
Section 1834(h)(4) of the Social Security Act (42 U.S.C.
1395m(h)(4)) is amended--
(1) in subparagraph (A)--
(A) in clause (ix), by striking ``and'' at the end;
(B) in clause (x)--
(i) by striking ``a subsequent year'' and inserting ``for
each of 2007 through 2010''; and
(ii) by inserting ``and'' after the semicolon at the end;
(C) by adding at the end the following new clause:
``(xi) for 2011 and each subsequent year--
``(I) the percentage increase in the consumer price index
for all urban consumers (United States city average) for the
12-month period ending with June of the previous year,
reduced by--
``(II) the productivity adjustment described in section
1886(b)(3)(B)(xi)(II).''; and
(D) by adding at the end the following flush sentence:
``The application of subparagraph (A)(xi)(II) may result in
the applicable percentage increase under subparagraph (A)
being less than 0.0 for a year, and may result in payment
rates under this subsection for a year being less than such
payment rates for the preceding year.''.
(o) Other Items.--Section 1842(s)(1) of the Social Security
Act (42 U.S.C. 1395u(s)(1)) is amended--
(1) in the first sentence, by striking ``Subject to'' and
inserting ``(A) Subject to'';
(2) by striking the second sentence and inserting the
following new subparagraph:
``(B) Any fee schedule established under this paragraph for
such item or service shall be updated--
``(i) for years before 2011--
``(I) subject to subclause (II), by the percentage increase
in the consumer price index for all urban consumers (United
States city average) for the 12-month period ending with June
of the preceding year; and
``(II) for items and services described in paragraph (2)(D)
for 2009, section 1834(a)(14)(J) shall apply under this
paragraph instead of the percentage increase otherwise
applicable; and
``(ii) for 2011 and subsequent years--
``(I) the percentage increase in the consumer price index
for all urban consumers (United States city average) for the
12-month period ending with June of the previous year,
reduced by--
``(II) the productivity adjustment described in section
1886(b)(3)(B)(xi)(II).''; and
(3) by adding at the end the following flush sentence:
``The application of subparagraph (B)(ii)(II) may result in
the update under this paragraph being less than 0.0 for a
year, and may result in payment rates under any fee schedule
established under this paragraph for a year being less than
such payment rates for the preceding year.''.
(p) No Application Prior to April 1, 2010.--Notwithstanding
the preceding provisions of this section, the amendments made
by subsections (a), (c), and (d) shall not apply to
discharges occurring before April 1, 2010.
SEC. 3402. TEMPORARY ADJUSTMENT TO THE CALCULATION OF PART B
PREMIUMS.
Section 1839(i) of the Social Security Act (42 U.S.C.
1395r(i)) is amended--
[[Page H2016]]
(1) in paragraph (2), in the matter preceding subparagraph
(A), by inserting ``subject to paragraph (6),'' after
``subsection,'';
(2) in paragraph (3)(A)(i), by striking ``The applicable''
and inserting ``Subject to paragraph (6), the applicable'';
(3) by redesignating paragraph (6) as paragraph (7); and
(4) by inserting after paragraph (5) the following new
paragraph:
``(6) Temporary adjustment to income thresholds.--
Notwithstanding any other provision of this subsection,
during the period beginning on January 1, 2011, and ending on
December 31, 2019--
``(A) the threshold amount otherwise applicable under
paragraph (2) shall be equal to such amount for 2010; and
``(B) the dollar amounts otherwise applicable under
paragraph (3)(C)(i) shall be equal to such dollar amounts for
2010.''.
SEC. 3403. INDEPENDENT MEDICARE ADVISORY BOARD.
(a) Board.--
(1) In general.--Title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.), as amended by section 3022, is amended
by adding at the end the following new section:
``independent medicare advisory board
``Sec. 1899A. (a) Establishment.--There is established an
independent board to be known as the `Independent Medicare
Advisory Board'.
``(b) Purpose.--It is the purpose of this section to, in
accordance with the following provisions of this section,
reduce the per capita rate of growth in Medicare spending--
``(1) by requiring the Chief Actuary of the Centers for
Medicare & Medicaid Services to determine in each year to
which this section applies (in this section referred to as `a
determination year') the projected per capita growth rate
under Medicare for the second year following the
determination year (in this section referred to as `an
implementation year');
``(2) if the projection for the implementation year exceeds
the target growth rate for that year, by requiring the Board
to develop and submit during the first year following the
determination year (in this section referred to as `a
proposal year') a proposal containing recommendations to
reduce the Medicare per capita growth rate to the extent
required by this section; and
``(3) by requiring the Secretary to implement such
proposals unless Congress enacts legislation pursuant to this
section.
``(c) Board Proposals.--
``(1) Development.--
``(A) In general.--The Board shall develop detailed and
specific proposals related to the Medicare program in
accordance with the succeeding provisions of this section.
``(B) Advisory reports.--Beginning January 15, 2014, the
Board may develop and submit to Congress advisory reports on
matters related to the Medicare program, regardless of
whether or not the Board submitted a proposal for such year.
Such a report may, for years prior to 2020, include
recommendations regarding improvements to payment systems for
providers of services and suppliers who are not otherwise
subject to the scope of the Board's recommendations in a
proposal under this section. Any advisory report submitted
under this subparagraph shall not be subject to the rules for
congressional consideration under subsection (d).
``(2) Proposals.--
``(A) Requirements.--Each proposal submitted under this
section in a proposal year shall meet each of the following
requirements:
``(i) If the Chief Actuary of the Centers for Medicare &
Medicaid Services has made a determination under paragraph
(7)(A) in the determination year, the proposal shall include
recommendations so that the proposal as a whole (after taking
into account recommendations under clause (v)) will result in
a net reduction in total Medicare program spending in the
implementation year that is at least equal to the applicable
savings target established under paragraph (7)(B) for such
implementation year. In determining whether a proposal meets
the requirement of the preceding sentence, reductions in
Medicare program spending during the 3-month period
immediately preceding the implementation year shall be
counted to the extent that such reductions are a result of
the implementation of recommendations contained in the
proposal for a change in the payment rate for an item or
service that was effective during such period pursuant to
subsection (e)(2)(A).
``(ii) The proposal shall not include any recommendation to
ration health care, raise revenues or Medicare beneficiary
premiums under section 1818, 1818A, or 1839, increase
Medicare beneficiary cost-sharing (including deductibles,
coinsurance, and copayments), or otherwise restrict benefits
or modify eligibility criteria.
``(iii) In the case of proposals submitted prior to
December 31, 2018, the proposal shall not include any
recommendation that would reduce payment rates for items and
services furnished, prior to December 31, 2019, by providers
of services (as defined in section 1861(u)) and suppliers (as
defined in section 1861(d)) scheduled, pursuant to the
amendments made by section 3401 of the Patient Protection and
Affordable Care Act, to receive a reduction to the
inflationary payment updates of such providers of services
and suppliers in excess of a reduction due to productivity in
a year in which such recommendations would take effect.
``(iv) As appropriate, the proposal shall include
recommendations to reduce Medicare payments under parts C and
D, such as reductions in direct subsidy payments to Medicare
Advantage and prescription drug plans specified under
paragraph (1) and (2) of section 1860D-15(a) that are related
to administrative expenses (including profits) for basic
coverage, denying high bids or removing high bids for
prescription drug coverage from the calculation of the
national average monthly bid amount under section 1860D-
13(a)(4), and reductions in payments to Medicare Advantage
plans under clauses (i) and (ii) of section 1853(a)(1)(B)
that are related to administrative expenses (including
profits) and performance bonuses for Medicare Advantage plans
under section 1853(n). Any such recommendation shall not
affect the base beneficiary premium percentage specified
under 1860D-13(a).
``(v) The proposal shall include recommendations with
respect to administrative funding for the Secretary to carry
out the recommendations contained in the proposal.
``(vi) The proposal shall only include recommendations
related to the Medicare program.
``(B) Additional considerations.--In developing and
submitting each proposal under this section in a proposal
year, the Board shall, to the extent feasible--
``(i) give priority to recommendations that extend Medicare
solvency;
``(ii) include recommendations that--
``(I) improve the health care delivery system and health
outcomes, including by promoting integrated care, care
coordination, prevention and wellness, and quality and
efficiency improvement; and
``(II) protect and improve Medicare beneficiaries' access
to necessary and evidence-based items and services, including
in rural and frontier areas;
``(iii) include recommendations that target reductions in
Medicare program spending to sources of excess cost growth;
``(iv) consider the effects on Medicare beneficiaries of
changes in payments to providers of services (as defined in
section 1861(u)) and suppliers (as defined in section
1861(d));
``(v) consider the effects of the recommendations on
providers of services and suppliers with actual or projected
negative cost margins or payment updates; and
``(vi) consider the unique needs of Medicare beneficiaries
who are dually eligible for Medicare and the Medicaid program
under title XIX.
``(C) No increase in total medicare program spending.--Each
proposal submitted under this section shall be designed in
such a manner that implementation of the recommendations
contained in the proposal would not be expected to result,
over the 10-year period starting with the implementation
year, in any increase in the total amount of net Medicare
program spending relative to the total amount of net Medicare
program spending that would have occurred absent such
implementation.
``(D) Consultation with medpac.--The Board shall submit a
draft copy of each proposal to be submitted under this
section to the Medicare Payment Advisory Commission
established under section 1805 for its review. The Board
shall submit such draft copy by not later than September 1 of
the determination year.
``(E) Review and comment by the secretary.--The Board shall
submit a draft copy of each proposal to be submitted to
Congress under this section to the Secretary for the
Secretary's review and comment. The Board shall submit such
draft copy by not later than September 1 of the determination
year. Not later than March 1 of the submission year, the
Secretary shall submit a report to Congress on the results of
such review, unless the Secretary submits a proposal under
paragraph (5)(A) in that year.
``(F) Consultations.--In carrying out its duties under this
section, the Board shall engage in regular consultations with
the Medicaid and CHIP Payment and Access Commission under
section 1900.
``(3) Transmission of board proposal to president.--
``(A) In general.--
``(i) In general.--Except as provided in clause (ii) and
subsection (f)(3)(B), the Board shall transmit a proposal
under this section to the President on January 15 of each
year (beginning with 2014).
``(ii) Exception.--The Board shall not submit a proposal
under clause (i) in a proposal year if the year is--
``(I) a year for which the Chief Actuary of the Centers for
Medicare & Medicaid Services makes a determination in the
determination year under paragraph (6)(A) that the growth
rate described in clause (i) of such paragraph does not
exceed the growth rate described in clause (ii) of such
paragraph;
``(II) a year in which the Chief Actuary of the Centers for
Medicare & Medicaid Services makes a determination in the
determination year that the projected percentage increase (if
any) for the medical care expenditure category of the
Consumer Price Index for All Urban Consumers (United States
city average) for the implementation year is less than the
projected percentage increase (if any) in the Consumer Price
Index for All Urban Consumers (all items; United States city
average) for such implementation year; or
``(III) for proposal year 2019 and subsequent proposal
years, a year in which the Chief Actuary of the Centers for
Medicare & Medicaid Services makes a determination in the
determination year that the growth rate described in
paragraph (8) exceeds the growth rate described in paragraph
(6)(A)(i).
``(iii) Start-up period.--The Board may not submit a
proposal under clause (i) prior to January 15, 2014.
``(B) Required information.--Each proposal submitted by the
Board under subparagraph (A)(i) shall include--
``(i) the recommendations described in paragraph (2)(A)(i);
``(ii) an explanation of each recommendation contained in
the proposal and the reasons for including such
recommendation;
``(iii) an actuarial opinion by the Chief Actuary of the
Centers for Medicare & Medicaid
[[Page H2017]]
Services certifying that the proposal meets the requirements
of subparagraphs (A)(i) and (C) of paragraph (2);
``(iv) a legislative proposal that implements the
recommendations; and
``(v) other information determined appropriate by the
Board.
``(4) Presidential submission to congress.--Upon receiving
a proposal from the Board under paragraph (3)(A)(i) or the
Secretary under paragraph (5), the President shall
immediately submit such proposal to Congress.
``(5) Contingent secretarial development of proposal.--If,
with respect to a proposal year, the Board is required, to
but fails, to submit a proposal to the President by the
deadline applicable under paragraph (3)(A)(i), the Secretary
shall develop a detailed and specific proposal that satisfies
the requirements of subparagraphs (A) and (C) (and, to the
extent feasible, subparagraph (B)) of paragraph (2) and
contains the information required paragraph (3)(B)). By not
later than January 25 of the year, the Secretary shall
transmit--
``(A) such proposal to the President; and
``(B) a copy of such proposal to the Medicare Payment
Advisory Commission for its review.
``(6) Per capita growth rate projections by chief
actuary.--
``(A) In general.--Subject to subsection (f)(3)(A), not
later than April 30, 2013, and annually thereafter, the Chief
Actuary of the Centers for Medicare & Medicaid Services shall
determine in each such year whether--
``(i) the projected Medicare per capita growth rate for the
implementation year (as determined under subparagraph (B));
exceeds
``(ii) the projected Medicare per capita target growth rate
for the implementation year (as determined under subparagraph
(C)).
``(B) Medicare per capita growth rate.--
``(i) In general.--For purposes of this section, the
Medicare per capita growth rate for an implementation year
shall be calculated as the projected 5-year average (ending
with such year) of the growth in Medicare program spending
per unduplicated enrollee.
``(ii) Requirement.--The projection under clause (i)
shall--
``(I) to the extent that there is projected to be a
negative update to the single conversion factor applicable to
payments for physicians' services under section 1848(d)
furnished in the proposal year or the implementation year,
assume that such update for such services is 0 percent rather
than the negative percent that would otherwise apply; and
``(II) take into account any delivery system reforms or
other payment changes that have been enacted or published in
final rules but not yet implemented as of the making of such
calculation.
``(C) Medicare per capita target growth rate.--For purposes
of this section, the Medicare per capita target growth rate
for an implementation year shall be calculated as the
projected 5-year average (ending with such year) percentage
increase in--
``(i) with respect to a determination year that is prior to
2018, the average of the projected percentage increase (if
any) in--
``(I) the Consumer Price Index for All Urban Consumers (all
items; United States city average); and
``(II) the medical care expenditure category of the
Consumer Price Index for All Urban Consumers (United States
city average); and
``(ii) with respect to a determination year that is after
2017, the nominal gross domestic product per capita plus 1.0
percentage point.
``(7) Savings requirement.--
``(A) In general.--If, with respect to a determination
year, the Chief Actuary of the Centers for Medicare &
Medicaid Services makes a determination under paragraph
(6)(A) that the growth rate described in clause (i) of such
paragraph exceeds the growth rate described in clause (ii) of
such paragraph, the Chief Actuary shall establish an
applicable savings target for the implementation year.
``(B) Applicable savings target.--For purposes of this
section, the applicable savings target for an implementation
year shall be an amount equal to the product of--
``(i) the total amount of projected Medicare program
spending for the proposal year; and
``(ii) the applicable percent for the implementation year.
``(C) Applicable percent.--For purposes of subparagraph
(B), the applicable percent for an implementation year is the
lesser of--
``(i) in the case of--
``(I) implementation year 2015, 0.5 percent;
``(II) implementation year 2016, 1.0 percent;
``(III) implementation year 2017, 1.25 percent; and
``(IV) implementation year 2018 or any subsequent
implementation year, 1.5 percent; and
``(ii) the projected excess for the implementation year
(expressed as a percent) determined under subparagraph (A).
``(8) Per capita rate of growth in national health
expenditures.--In each determination year (beginning in
2018), the Chief Actuary of the Centers for Medicare &
Medicaid Services shall project the per capita rate of growth
in national health expenditures for the implementation year.
Such rate of growth for an implementation year shall be
calculated as the projected 5-year average (ending with such
year) percentage increase in national health care
expenditures.
``(d) Congressional Consideration.--
``(1) Introduction.--
``(A) In general.--On the day on which a proposal is
submitted by the President to the House of Representatives
and the Senate under subsection (c)(4), the legislative
proposal (described in subsection (c)(3)(B)(iv)) contained in
the proposal shall be introduced (by request) in the Senate
by the majority leader of the Senate or by Members of the
Senate designated by the majority leader of the Senate and
shall be introduced (by request) in the House by the majority
leader of the House or by Members of the House designated by
the majority leader of the House.
``(B) Not in session.--If either House is not in session on
the day on which such legislative proposal is submitted, the
legislative proposal shall be introduced in that House, as
provided in subparagraph (A), on the first day thereafter on
which that House is in session.
``(C) Any member.--If the legislative proposal is not
introduced in either House within 5 days on which that House
is in session after the day on which the legislative proposal
is submitted, then any Member of that House may introduce the
legislative proposal.
``(D) Referral.--The legislation introduced under this
paragraph shall be referred by the Presiding Officers of the
respective Houses to the Committee on Finance in the Senate
and to the Committee on Energy and Commerce and the Committee
on Ways and Means in the House of Representatives.
``(2) Committee consideration of proposal.--
``(A) Reporting bill.--Not later than April 1 of any
proposal year in which a proposal is submitted by the
President to Congress under this section, the Committee on
Ways and Means and the Committee on Energy and Commerce of
the House of Representatives and the Committee on Finance of
the Senate may report the bill referred to the Committee
under paragraph (1)(D) with committee amendments related to
the Medicare program.
``(B) Calculations.--In determining whether a committee
amendment meets the requirement of subparagraph (A), the
reductions in Medicare program spending during the 3-month
period immediately preceding the implementation year shall be
counted to the extent that such reductions are a result of
the implementation provisions in the committee amendment for
a change in the payment rate for an item or service that was
effective during such period pursuant to such amendment.
``(C) Committee jurisdiction.--Notwithstanding rule XV of
the Standing Rules of the Senate, a committee amendment
described in subparagraph (A) may include matter not within
the jurisdiction of the Committee on Finance if that matter
is relevant to a proposal contained in the bill submitted
under subsection (c)(3).
``(D) Discharge.--If, with respect to the House involved,
the committee has not reported the bill by the date required
by subparagraph (A), the committee shall be discharged from
further consideration of the proposal.
``(3) Limitation on changes to the board recommendations.--
``(A) In general.--It shall not be in order in the Senate
or the House of Representatives to consider any bill,
resolution, or amendment, pursuant to this subsection or
conference report thereon, that fails to satisfy the
requirements of subparagraphs (A)(i) and (C) of subsection
(c)(2).
``(B) Limitation on changes to the board recommendations in
other legislation.--It shall not be in order in the Senate or
the House of Representatives to consider any bill,
resolution, amendment, or conference report (other than
pursuant to this section) that would repeal or otherwise
change the recommendations of the Board if that change would
fail to satisfy the requirements of subparagraphs (A)(i) and
(C) of subsection (c)(2).
``(C) Limitation on changes to this subsection.--It shall
not be in order in the Senate or the House of Representatives
to consider any bill, resolution, amendment, or conference
report that would repeal or otherwise change this subsection.
``(D) Waiver.--This paragraph may be waived or suspended in
the Senate only by the affirmative vote of three-fifths of
the Members, duly chosen and sworn.
``(E) Appeals.--An affirmative vote of three-fifths of the
Members of the Senate, duly chosen and sworn, shall be
required in the Senate to sustain an appeal of the ruling of
the Chair on a point of order raised under this paragraph.
``(4) Expedited procedure.--
``(A) Consideration.--A motion to proceed to the
consideration of the bill in the Senate is not debatable.
``(B) Amendment.--
``(i) Time limitation.--Debate in the Senate on any
amendment to a bill under this section shall be limited to 1
hour, to be equally divided between, and controlled by, the
mover and the manager of the bill, and debate on any
amendment to an amendment, debatable motion, or appeal shall
be limited to 30 minutes, to be equally divided between, and
controlled by, the mover and the manager of the bill, except
that in the event the manager of the bill is in favor of any
such amendment, motion, or appeal, the time in opposition
thereto shall be controlled by the minority leader or such
leader's designee.
``(ii) Germane.--No amendment that is not germane to the
provisions of such bill shall be received.
``(iii) Additional time.--The leaders, or either of them,
may, from the time under their control on the passage of the
bill, allot additional time to any Senator during the
consideration of any amendment, debatable motion, or appeal.
``(iv) Amendment not in order.--It shall not be in order to
consider an amendment that would cause the bill to result in
a net reduction in total Medicare program spending in the
implementation year that is less than the applicable savings
target established under subsection (c)(7)(B) for such
implementation year.
``(v) Waiver and appeals.--This paragraph may be waived or
suspended in the Senate only by the affirmative vote of
three-fifths of the Members, duly chosen and sworn. An
affirmative vote of three-fifths of the Members of the
[[Page H2018]]
Senate, duly chosen and sworn, shall be required in the
Senate to sustain an appeal of the ruling of the Chair on a
point of order raised under this section.
``(C) Consideration by the other house.--
``(i) In general.--The expedited procedures provided in
this subsection for the consideration of a bill introduced
pursuant to paragraph (1) shall not apply to such a bill that
is received by one House from the other House if such a bill
was not introduced in the receiving House.
``(ii) Before passage.--If a bill that is introduced
pursuant to paragraph (1) is received by one House from the
other House, after introduction but before disposition of
such a bill in the receiving House, then the following shall
apply:
``(I) The receiving House shall consider the bill
introduced in that House through all stages of consideration
up to, but not including, passage.
``(II) The question on passage shall be put on the bill of
the other House as amended by the language of the receiving
House.
``(iii) After passage.--If a bill introduced pursuant to
paragraph (1) is received by one House from the other House,
after such a bill is passed by the receiving House, then the
vote on passage of the bill that originates in the receiving
House shall be considered to be the vote on passage of the
bill received from the other House as amended by the language
of the receiving House.
``(iv) Disposition.--Upon disposition of a bill introduced
pursuant to paragraph (1) that is received by one House from
the other House, it shall no longer be in order to consider
the bill that originates in the receiving House.
``(v) Limitation.--Clauses (ii), (iii), and (iv) shall
apply only to a bill received by one House from the other
House if the bill--
``(I) is related only to the program under this title; and
``(II) satisfies the requirements of subparagraphs (A)(i)
and (C) of subsection (c)(2).
``(D) Senate limits on debate.--
``(i) In general.--In the Senate, consideration of the bill
and on all debatable motions and appeals in connection
therewith shall not exceed a total of 30 hours, which shall
be divided equally between the majority and minority leaders
or their designees.
``(ii) Motion to further limit debate.--A motion to further
limit debate on the bill is in order and is not debatable.
``(iii) Motion or appeal.--Any debatable motion or appeal
is debatable for not to exceed 1 hour, to be divided equally
between those favoring and those opposing the motion or
appeal.
``(iv) Final disposition.--After 30 hours of consideration,
the Senate shall proceed, without any further debate on any
question, to vote on the final disposition thereof to the
exclusion of all amendments not then pending before the
Senate at that time and to the exclusion of all motions,
except a motion to table, or to reconsider and one quorum
call on demand to establish the presence of a quorum (and
motions required to establish a quorum) immediately before
the final vote begins.
``(E) Consideration in conference.--
``(i) In general.--Consideration in the Senate and the
House of Representatives on the conference report or any
messages between Houses shall be limited to 10 hours, equally
divided and controlled by the majority and minority leaders
of the Senate or their designees and the Speaker of the House
of Representatives and the minority leader of the House of
Representatives or their designees.
``(ii) Time limitation.--Debate in the Senate on any
amendment under this subparagraph shall be limited to 1 hour,
to be equally divided between, and controlled by, the mover
and the manager of the bill, and debate on any amendment to
an amendment, debatable motion, or appeal shall be limited to
30 minutes, to be equally divided between, and controlled by,
the mover and the manager of the bill, except that in the
event the manager of the bill is in favor of any such
amendment, motion, or appeal, the time in opposition thereto
shall be controlled by the minority leader or such leader's
designee.
``(iii) Final disposition.--After 10 hours of
consideration, the Senate shall proceed, without any further
debate on any question, to vote on the final disposition
thereof to the exclusion of all motions not then pending
before the Senate at that time or necessary to resolve the
differences between the Houses and to the exclusion of all
other motions, except a motion to table, or to reconsider and
one quorum call on demand to establish the presence of a
quorum (and motions required to establish a quorum)
immediately before the final vote begins.
``(iv) Limitation.--Clauses (i) through (iii) shall only
apply to a conference report, message or the amendments
thereto if the conference report, message, or an amendment
thereto--
``(I) is related only to the program under this title; and
``(II) satisfies the requirements of subparagraphs (A)(i)
and (C) of subsection (c)(2).
``(F) Veto.--If the President vetoes the bill debate on a
veto message in the Senate under this subsection shall be 1
hour equally divided between the majority and minority
leaders or their designees.
``(5) Rules of the senate and house of representatives.--
This subsection and subsection (f)(2) are enacted by
Congress--
``(A) as an exercise of the rulemaking power of the Senate
and the House of Representatives, respectively, and is deemed
to be part of the rules of each House, respectively, but
applicable only with respect to the procedure to be followed
in that House in the case of bill under this section, and it
supersedes other rules only to the extent that it is
inconsistent with such rules; and
``(B) with full recognition of the constitutional right of
either House to change the rules (so far as they relate to
the procedure of that House) at any time, in the same manner,
and to the same extent as in the case of any other rule of
that House.
``(e) Implementation of Proposal.--
``(1) In general.--Notwithstanding any other provision of
law, the Secretary shall, except as provided in paragraph
(3), implement the recommendations contained in a proposal
submitted by the President to Congress pursuant to this
section on August 15 of the year in which the proposal is so
submitted.
``(2) Application.--
``(A) In general.--A recommendation described in paragraph
(1) shall apply as follows:
``(i) In the case of a recommendation that is a change in
the payment rate for an item or service under Medicare in
which payment rates change on a fiscal year basis (or a cost
reporting period basis that relates to a fiscal year), on a
calendar year basis (or a cost reporting period basis that
relates to a calendar year), or on a rate year basis (or a
cost reporting period basis that relates to a rate year),
such recommendation shall apply to items and services
furnished on the first day of the first fiscal year, calendar
year, or rate year (as the case may be) that begins after
such August 15.
``(ii) In the case of a recommendation relating to payments
to plans under parts C and D, such recommendation shall apply
to plan years beginning on the first day of the first
calendar year that begins after such August 15.
``(iii) In the case of any other recommendation, such
recommendation shall be addressed in the regular regulatory
process timeframe and shall apply as soon as practicable.
``(B) Interim final rulemaking.--The Secretary may use
interim final rulemaking to implement any recommendation
described in paragraph (1).
``(3) Exception.--The Secretary shall not be required to
implement the recommendations contained in a proposal
submitted in a proposal year by the President to Congress
pursuant to this section if--
``(A) prior to August 15 of the proposal year, Federal
legislation is enacted that includes the following provision:
`This Act supercedes the recommendations of the Board
contained in the proposal submitted, in the year which
includes the date of enactment of this Act, to Congress under
section 1899A of the Social Security Act.'; and
``(B) in the case of implementation year 2020 and
subsequent implementation years, a joint resolution described
in subsection (f)(1) is enacted not later than August 15,
2017.
``(4) No affect on authority to implement certain
provisions.--Nothing in paragraph (3) shall be construed to
affect the authority of the Secretary to implement any
recommendation contained in a proposal or advisory report
under this section to the extent that the Secretary otherwise
has the authority to implement such recommendation
administratively.
``(5) Limitation on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of the implementation by the Secretary
under this subsection of the recommendations contained in a
proposal.
``(f) Joint Resolution Required To Discontinue the Board.--
``(1) In general.--For purposes of subsection (e)(3)(B), a
joint resolution described in this paragraph means only a
joint resolution--
``(A) that is introduced in 2017 by not later than February
1 of such year;
``(B) which does not have a preamble;
``(C) the title of which is as follows: `Joint resolution
approving the discontinuation of the process for
consideration and automatic implementation of the annual
proposal of the Independent Medicare Advisory Board under
section 1899A of the Social Security Act'; and
``(D) the matter after the resolving clause of which is as
follows: `That Congress approves the discontinuation of the
process for consideration and automatic implementation of the
annual proposal of the Independent Medicare Advisory Board
under section 1899A of the Social Security Act.'.
``(2) Procedure.--
``(A) Referral.--A joint resolution described in paragraph
(1) shall be referred to the Committee on Ways and Means and
the Committee on Energy and Commerce of the House of
Representatives and the Committee on Finance of the Senate.
``(B) Discharge.--In the Senate, if the committee to which
is referred a joint resolution described in paragraph (1) has
not reported such joint resolution (or an identical joint
resolution) at the end of 20 days after the joint resolution
described in paragraph (1) is introduced, such committee may
be discharged from further consideration of such joint
resolution upon a petition supported in writing by 30 Members
of the Senate, and such joint resolution shall be placed on
the calendar.
``(C) Consideration.--
``(i) In general.--In the Senate, when the committee to
which a joint resolution is referred has reported, or when a
committee is discharged (under subparagraph (C)) from further
consideration of a joint resolution described in paragraph
(1), it is at any time thereafter in order (even though a
previous motion to the same effect has been disagreed to) for
a motion to proceed to the consideration of the joint
resolution to be made, and all points of order against the
joint resolution (and against consideration of the joint
resolution) are waived, except for points of order under the
Congressional Budget act of 1974 or under budget resolutions
pursuant to that Act. The motion is not debatable. A motion
to reconsider the vote by which the motion is agreed to or
disagreed to shall not be in order. If a motion to proceed to
the consideration of the joint resolution is agreed to, the
joint resolution shall remain the unfinished business of the
Senate until disposed of.
[[Page H2019]]
``(ii) Debate limitation.--In the Senate, consideration of
the joint resolution, and on all debatable motions and
appeals in connection therewith, shall be limited to not more
than 10 hours, which shall be divided equally between the
majority leader and the minority leader, or their designees.
A motion further to limit debate is in order and not
debatable. An amendment to, or a motion to postpone, or a
motion to proceed to the consideration of other business, or
a motion to recommit the joint resolution is not in order.
``(iii) Passage.--In the Senate, immediately following the
conclusion of the debate on a joint resolution described in
paragraph (1), and a single quorum call at the conclusion of
the debate if requested in accordance with the rules of the
Senate, the vote on passage of the joint resolution shall
occur.
``(iv) Appeals.--Appeals from the decisions of the Chair
relating to the application of the rules of the Senate to the
procedure relating to a joint resolution described in
paragraph (1) shall be decided without debate.
``(D) Other house acts first.--If, before the passage by 1
House of a joint resolution of that House described in
paragraph (1), that House receives from the other House a
joint resolution described in paragraph (1), then the
following procedures shall apply:
``(i) The joint resolution of the other House shall not be
referred to a committee.
``(ii) With respect to a joint resolution described in
paragraph (1) of the House receiving the joint resolution--
``(I) the procedure in that House shall be the same as if
no joint resolution had been received from the other House;
but
``(II) the vote on final passage shall be on the joint
resolution of the other House.
``(E) Excluded days.--For purposes of determining the
period specified in subparagraph (B), there shall be excluded
any days either House of Congress is adjourned for more than
3 days during a session of Congress.
``(F) Majority required for adoption.--A joint resolution
considered under this subsection shall require an affirmative
vote of three-fifths of the Members, duly chosen and sworn,
for adoption.
``(3) Termination.--If a joint resolution described in
paragraph (1) is enacted not later than August 15, 2017--
``(A) the Chief Actuary of the Medicare & Medicaid Services
shall not--
``(i) make any determinations under subsection (c)(6) after
May 1, 2017; or
``(ii) provide any opinion pursuant to subsection
(c)(3)(B)(iii) after January 16, 2018;
``(B) the Board shall not submit any proposals or advisory
reports to Congress under this section after January 16,
2018; and
``(C) the Board and the consumer advisory council under
subsection (k) shall terminate on August 16, 2018.
``(g) Board Membership; Terms of Office; Chairperson;
Removal.--
``(1) Membership.--
``(A) In general.--The Board shall be composed of--
``(i) 15 members appointed by the President, by and with
the advice and consent of the Senate; and
``(ii) the Secretary, the Administrator of the Center for
Medicare & Medicaid Services, and the Administrator of the
Health Resources and Services Administration, all of whom
shall serve ex officio as nonvoting members of the Board.
``(B) Qualifications.--
``(i) In general.--The appointed membership of the Board
shall include individuals with national recognition for their
expertise in health finance and economics, actuarial science,
health facility management, health plans and integrated
delivery systems, reimbursement of health facilities,
allopathic and osteopathic physicians, and other providers of
health services, and other related fields, who provide a mix
of different professionals, broad geographic representation,
and a balance between urban and rural representatives.
``(ii) Inclusion.--The appointed membership of the Board
shall include (but not be limited to) physicians and other
health professionals, experts in the area of pharmaco-
economics or prescription drug benefit programs, employers,
third-party payers, individuals skilled in the conduct and
interpretation of biomedical, health services, and health
economics research and expertise in outcomes and
effectiveness research and technology assessment. Such
membership shall also include representatives of consumers
and the elderly.
``(iii) Majority nonproviders.--Individuals who are
directly involved in the provision or management of the
delivery of items and services covered under this title shall
not constitute a majority of the appointed membership of the
Board.
``(C) Ethical disclosure.--The President shall establish a
system for public disclosure by appointed members of the
Board of financial and other potential conflicts of interest
relating to such members. Appointed members of the Board
shall be treated as officers in the executive branch for
purposes of applying title I of the Ethics in Government Act
of 1978 (Public Law 95-521).
``(D) Conflicts of interest.--No individual may serve as an
appointed member if that individual engages in any other
business, vocation, or employment.
``(E) Consultation with congress.--In selecting individuals
for nominations for appointments to the Board, the President
shall consult with--
``(i) the majority leader of the Senate concerning the
appointment of 3 members;
``(ii) the Speaker of the House of Representatives
concerning the appointment of 3 members;
``(iii) the minority leader of the Senate concerning the
appointment of 3 members; and
``(iv) the minority leader of the House of Representatives
concerning the appointment of 3 members.
``(2) Term of office.--Each appointed member shall hold
office for a term of 6 years except that--
``(A) a member may not serve more than 2 full consecutive
terms (but may be reappointed to 2 full consecutive terms
after being appointed to fill a vacancy on the Board);
``(B) a member appointed to fill a vacancy occurring prior
to the expiration of the term for which that member's
predecessor was appointed shall be appointed for the
remainder of such term;
``(C) a member may continue to serve after the expiration
of the member's term until a successor has taken office; and
``(D) of the members first appointed under this section, 5
shall be appointed for a term of 1 year, 5 shall be appointed
for a term of 3 years, and 5 shall be appointed for a term of
6 years, the term of each to be designated by the President
at the time of nomination.
``(3) Chairperson.--
``(A) In general.--The Chairperson shall be appointed by
the President, by and with the advice and consent of the
Senate, from among the members of the Board.
``(B) Duties.--The Chairperson shall be the principal
executive officer of the Board, and shall exercise all of the
executive and administrative functions of the Board,
including functions of the Board with respect to--
``(i) the appointment and supervision of personnel employed
by the Board;
``(ii) the distribution of business among personnel
appointed and supervised by the Chairperson and among
administrative units of the Board; and
``(iii) the use and expenditure of funds.
``(C) Governance.--In carrying out any of the functions
under subparagraph (B), the Chairperson shall be governed by
the general policies established by the Board and by the
decisions, findings, and determinations the Board shall by
law be authorized to make.
``(D) Requests for appropriations.--Requests or estimates
for regular, supplemental, or deficiency appropriations on
behalf of the Board may not be submitted by the Chairperson
without the prior approval of a majority vote of the Board.
``(4) Removal.--Any appointed member may be removed by the
President for neglect of duty or malfeasance in office, but
for no other cause.
``(h) Vacancies; Quorum; Seal; Vice Chairperson; Voting on
Reports.--
``(1) Vacancies.--No vacancy on the Board shall impair the
right of the remaining members to exercise all the powers of
the Board.
``(2) Quorum.--A majority of the appointed members of the
Board shall constitute a quorum for the transaction of
business, but a lesser number of members may hold hearings.
``(3) Seal.--The Board shall have an official seal, of
which judicial notice shall be taken.
``(4) Vice chairperson.--The Board shall annually elect a
Vice Chairperson to act in the absence or disability of the
Chairperson or in case of a vacancy in the office of the
Chairperson.
``(5) Voting on proposals.--Any proposal of the Board must
be approved by the majority of appointed members present.
``(i) Powers of the Board.--
``(1) Hearings.--The Board may hold such hearings, sit and
act at such times and places, take such testimony, and
receive such evidence as the Board considers advisable to
carry out this section.
``(2) Authority to inform research priorities for data
collection.--The Board may advise the Secretary on priorities
for health services research, particularly as such priorities
pertain to necessary changes and issues regarding payment
reforms under Medicare.
``(3) Obtaining official data.--The Board may secure
directly from any department or agency of the United States
information necessary to enable it to carry out this section.
Upon request of the Chairperson, the head of that department
or agency shall furnish that information to the Board on an
agreed upon schedule.
``(4) Postal services.--The Board may use the United States
mails in the same manner and under the same conditions as
other departments and agencies of the Federal Government.
``(5) Gifts.--The Board may accept, use, and dispose of
gifts or donations of services or property.
``(6) Offices.--The Board shall maintain a principal office
and such field offices as it determines necessary, and may
meet and exercise any of its powers at any other place.
``(j) Personnel Matters.--
``(1) Compensation of members and chairperson.--Each
appointed member, other than the Chairperson, shall be
compensated at a rate equal to the annual rate of basic pay
prescribed for level III of the Executive Schedule under
section 5315 of title 5, United States Code. The Chairperson
shall be compensated at a rate equal to the daily equivalent
of the annual rate of basic pay prescribed for level II of
the Executive Schedule under section 5315 of title 5, United
States Code.
``(2) Travel expenses.--The appointed members shall be
allowed travel expenses, including per diem in lieu of
subsistence, at rates authorized for employees of agencies
under subchapter I of chapter 57 of title 5, United States
Code, while away from their homes or regular places of
business in the performance of services for the Board.
``(3) Staff.--
``(A) In general.--The Chairperson may, without regard to
the civil service laws and regulations, appoint and terminate
an executive director and such other additional personnel as
may be necessary to enable the Board to perform its duties.
The employment of an executive director shall be subject to
confirmation by the Board.
[[Page H2020]]
``(B) Compensation.--The Chairperson may fix the
compensation of the executive director and other personnel
without regard to chapter 51 and subchapter III of chapter 53
of title 5, United States Code, relating to classification of
positions and General Schedule pay rates, except that the
rate of pay for the executive director and other personnel
may not exceed the rate payable for level V of the Executive
Schedule under section 5316 of such title.
``(4) Detail of government employees.--Any Federal
Government employee may be detailed to the Board without
reimbursement, and such detail shall be without interruption
or loss of civil service status or privilege.
``(5) Procurement of temporary and intermittent services.--
The Chairperson may procure temporary and intermittent
services under section 3109(b) of title 5, United States
Code, at rates for individuals which do not exceed the daily
equivalent of the annual rate of basic pay prescribed for
level V of the Executive Schedule under section 5316 of such
title.
``(k) Consumer Advisory Council.--
``(1) In general.--There is established a consumer advisory
council to advise the Board on the impact of payment policies
under this title on consumers.
``(2) Membership.--
``(A) Number and appointment.--The consumer advisory
council shall be composed of 10 consumer representatives
appointed by the Comptroller General of the United States, 1
from among each of the 10 regions established by the
Secretary as of the date of enactment of this section.
``(B) Qualifications.--The membership of the council shall
represent the interests of consumers and particular
communities.
``(3) Duties.--The consumer advisory council shall, subject
to the call of the Board, meet not less frequently than 2
times each year in the District of Columbia.
``(4) Open meetings.--Meetings of the consumer advisory
council shall be open to the public.
``(5) Election of officers.--Members of the consumer
advisory council shall elect their own officers.
``(6) Application of faca.--The Federal Advisory Committee
Act (5 U.S.C. App.) shall apply to the consumer advisory
council except that section 14 of such Act shall not apply.
``(l) Definitions.--In this section:
``(1) Board; chairperson; member.--The terms `Board',
`Chairperson', and `Member' mean the Independent Medicare
Advisory Board established under subsection (a) and the
Chairperson and any Member thereof, respectively.
``(2) Medicare.--The term `Medicare' means the program
established under this title, including parts A, B, C, and D.
``(3) Medicare beneficiary.--The term `Medicare
beneficiary' means an individual who is entitled to, or
enrolled for, benefits under part A or enrolled for benefits
under part B.
``(4) Medicare program spending.--The term `Medicare
program spending' means program spending under parts A, B,
and D net of premiums.
``(m) Funding.--
``(1) In general.--There are appropriated to the Board to
carry out its duties and functions--
``(A) for fiscal year 2012, $15,000,000; and
``(B) for each subsequent fiscal year, the amount
appropriated under this paragraph for the previous fiscal
year increased by the annual percentage increase in the
Consumer Price Index for All Urban Consumers (all items;
United States city average) as of June of the previous fiscal
year.
``(2) From trust funds.--Sixty percent of amounts
appropriated under paragraph (1) shall be derived by transfer
from the Federal Hospital Insurance Trust Fund under section
1817 and 40 percent of amounts appropriated under such
paragraph shall be derived by transfer from the Federal
Supplementary Medical Insurance Trust Fund under section
1841.''.
(2) Lobbying cooling-off period for members of the
independent medicare advisory board.--Section 207(c) of title
18, United States Code, is amended by inserting at the end
the following:
``(3) Members of the independent medicare advisory board.--
``(A) In general.--Paragraph (1) shall apply to a member of
the Independent Medicare Advisory Board under section 1899A.
``(B) Agencies and congress.--For purposes of paragraph
(1), the agency in which the individual described in
subparagraph (A) served shall be considered to be the
Independent Medicare Advisory Board, the Department of Health
and Human Services, and the relevant committees of
jurisdiction of Congress, including the Committee on Ways and
Means and the Committee on Energy and Commerce of the House
of Representatives and the Committee on Finance of the
Senate.''.
(b) GAO Study and Report on Determination and
Implementation of Payment and Coverage Policies Under the
Medicare Program.--
(1) Initial study and report.--
(A) Study.--The Comptroller General of the United States
(in this section referred to as the ``Comptroller General'')
shall conduct a study on changes to payment policies,
methodologies, and rates and coverage policies and
methodologies under the Medicare program under title XVIII of
the Social Security Act as a result of the recommendations
contained in the proposals made by the Independent Medicare
Advisory Board under section 1899A of such Act (as added by
subsection (a)), including an analysis of the effect of such
recommendations on--
(i) Medicare beneficiary access to providers and items and
services;
(ii) the affordability of Medicare premiums and cost-
sharing (including deductibles, coinsurance, and copayments);
(iii) the potential impact of changes on other government
or private-sector purchasers and payers of care; and
(iv) quality of patient care, including patient experience,
outcomes, and other measures of care.
(B) Report.--Not later than July 1, 2015, the Comptroller
General shall submit to Congress a report containing the
results of the study conducted under subparagraph (A),
together with recommendations for such legislation and
administrative action as the Comptroller General determines
appropriate.
(2) Subsequent studies and reports.--The Comptroller
General shall periodically conduct such additional studies
and submit reports to Congress on changes to Medicare
payments policies, methodologies, and rates and coverage
policies and methodologies as the Comptroller General
determines appropriate, in consultation with the Committee on
Ways and Means and the Committee on Energy and Commerce of
the House of Representatives and the Committee on Finance of
the Senate.
(c) Conforming Amendments.--Section 1805(b) of the Social
Security Act (42 U.S.C. 1395b-6(b)) is amended--
(1) by redesignating paragraphs (4) through (8) as
paragraphs (5) through (9), respectively; and
(2) by inserting after paragraph (3) the following:
``(4) Review and comment on the independent medicare
advisory board or secretarial proposal.--If the Independent
Medicare Advisory Board (as established under subsection (a)
of section 1899A) or the Secretary submits a proposal to the
Commission under such section in a year, the Commission shall
review the proposal and, not later than March 1 of that year,
submit to the Committee on Ways and Means and the Committee
on Energy and Commerce of the House of Representatives and
the Committee on Finance of the Senate written comments on
such proposal. Such comments may include such recommendations
as the Commission deems appropriate.''.
Subtitle F--Health Care Quality Improvements
SEC. 3501. HEALTH CARE DELIVERY SYSTEM RESEARCH; QUALITY
IMPROVEMENT TECHNICAL ASSISTANCE.
Part D of title IX of the Public Health Service Act, as
amended by section 3013, is further amended by adding at the
end the following:
``Subpart II--Health Care Quality Improvement Programs
``SEC. 933. HEALTH CARE DELIVERY SYSTEM RESEARCH.
``(a) Purpose.--The purposes of this section are to--
``(1) enable the Director to identify, develop, evaluate,
disseminate, and provide training in innovative methodologies
and strategies for quality improvement practices in the
delivery of health care services that represent best
practices (referred to as `best practices') in health care
quality, safety, and value; and
``(2) ensure that the Director is accountable for
implementing a model to pursue such research in a
collaborative manner with other related Federal agencies.
``(b) General Functions of the Center.--The Center for
Quality Improvement and Patient Safety of the Agency for
Healthcare Research and Quality (referred to in this section
as the `Center'), or any other relevant agency or department
designated by the Director, shall--
``(1) carry out its functions using research from a variety
of disciplines, which may include epidemiology, health
services, sociology, psychology, human factors engineering,
biostatistics, health economics, clinical research, and
health informatics;
``(2) conduct or support activities consistent with the
purposes described in subsection (a), and for--
``(A) best practices for quality improvement practices in
the delivery of health care services; and
``(B) that include changes in processes of care and the
redesign of systems used by providers that will reliably
result in intended health outcomes, improve patient safety,
and reduce medical errors (such as skill development for
health care providers in team-based health care delivery and
rapid cycle process improvement) and facilitate adoption of
improved workflow;
``(3) identify health care providers, including health care
systems, single institutions, and individual providers,
that--
``(A) deliver consistently high-quality, efficient health
care services (as determined by the Secretary); and
``(B) employ best practices that are adaptable and scalable
to diverse health care settings or effective in improving
care across diverse settings;
``(4) assess research, evidence, and knowledge about what
strategies and methodologies are most effective in improving
health care delivery;
``(5) find ways to translate such information rapidly and
effectively into practice, and document the sustainability of
those improvements;
``(6) create strategies for quality improvement through the
development of tools, methodologies, and interventions that
can successfully reduce variations in the delivery of health
care;
``(7) identify, measure, and improve organizational, human,
or other causative factors, including those related to the
culture and system design of a health care organization, that
contribute to the success and sustainability of specific
quality improvement and patient safety strategies;
``(8) provide for the development of best practices in the
delivery of health care services that--
``(A) have a high likelihood of success, based on
structured review of empirical evidence;
[[Page H2021]]
``(B) are specified with sufficient detail of the
individual processes, steps, training, skills, and knowledge
required for implementation and incorporation into workflow
of health care practitioners in a variety of settings;
``(C) are designed to be readily adapted by health care
providers in a variety of settings; and
``(D) where applicable, assist health care providers in
working with other health care providers across the continuum
of care and in engaging patients and their families in
improving the care and patient health outcomes;
``(9) provide for the funding of the activities of
organizations with recognized expertise and excellence in
improving the delivery of health care services, including
children's health care, by involving multiple disciplines,
managers of health care entities, broad development and
training, patients, caregivers and families, and frontline
health care workers, including activities for the examination
of strategies to share best quality improvement practices and
to promote excellence in the delivery of health care
services; and
``(10) build capacity at the State and community level to
lead quality and safety efforts through education, training,
and mentoring programs to carry out the activities under
paragraphs (1) through (9).
``(c) Research Functions of Center.--
``(1) In general.--The Center shall support, such as
through a contract or other mechanism, research on health
care delivery system improvement and the development of tools
to facilitate adoption of best practices that improve the
quality, safety, and efficiency of health care delivery
services. Such support may include establishing a Quality
Improvement Network Research Program for the purpose of
testing, scaling, and disseminating of interventions to
improve quality and efficiency in health care. Recipients of
funding under the Program may include national, State, multi-
State, or multi-site quality improvement networks.
``(2) Research requirements.--The research conducted
pursuant to paragraph (1) shall--
``(A) address the priorities identified by the Secretary in
the national strategic plan established under section 399HH;
``(B) identify areas in which evidence is insufficient to
identify strategies and methodologies, taking into
consideration areas of insufficient evidence identified by
the entity with a contract under section 1890(a) of the
Social Security Act in the report required under section
399JJ;
``(C) address concerns identified by health care
institutions and providers and communicated through the
Center pursuant to subsection (d);
``(D) reduce preventable morbidity, mortality, and
associated costs of morbidity and mortality by building
capacity for patient safety research;
``(E) support the discovery of processes for the reliable,
safe, efficient, and responsive delivery of health care,
taking into account discoveries from clinical research and
comparative effectiveness research;
``(F) allow communication of research findings and
translate evidence into practice recommendations that are
adaptable to a variety of settings, and which, as soon as
practicable after the establishment of the Center, shall
include--
``(i) the implementation of a national application of
Intensive Care Unit improvement projects relating to the
adult (including geriatric), pediatric, and neonatal patient
populations;
``(ii) practical methods for addressing health care
associated infections, including Methicillin-Resistant
Staphylococcus Aureus and Vancomycin-Resistant Entercoccus
infections and other emerging infections; and
``(iii) practical methods for reducing preventable hospital
admissions and readmissions;
``(G) expand demonstration projects for improving the
quality of children's health care and the use of health
information technology, such as through Pediatric Quality
Improvement Collaboratives and Learning Networks, consistent
with provisions of section 1139A of the Social Security Act
for assessing and improving quality, where applicable;
``(H) identify and mitigate hazards by--
``(i) analyzing events reported to patient safety reporting
systems and patient safety organizations; and
``(ii) using the results of such analyses to develop
scientific methods of response to such events;
``(I) include the conduct of systematic reviews of existing
practices that improve the quality, safety, and efficiency of
health care delivery, as well as new research on improving
such practices; and
``(J) include the examination of how to measure and
evaluate the progress of quality and patient safety
activities.
``(d) Dissemination of Research Findings.--
``(1) Public availability.--The Director shall make the
research findings of the Center available to the public
through multiple media and appropriate formats to reflect the
varying needs of health care providers and consumers and
diverse levels of health literacy.
``(2) Linkage to health information technology.--The
Secretary shall ensure that research findings and results
generated by the Center are shared with the Office of the
National Coordinator of Health Information Technology and
used to inform the activities of the health information
technology extension program under section 3012, as well as
any relevant standards, certification criteria, or
implementation specifications.
``(e) Prioritization.--The Director shall identify and
regularly update a list of processes or systems on which to
focus research and dissemination activities of the Center,
taking into account--
``(1) the cost to Federal health programs;
``(2) consumer assessment of health care experience;
``(3) provider assessment of such processes or systems and
opportunities to minimize distress and injury to the health
care workforce;
``(4) the potential impact of such processes or systems on
health status and function of patients, including vulnerable
populations including children;
``(5) the areas of insufficient evidence identified under
subsection (c)(2)(B); and
``(6) the evolution of meaningful use of health information
technology, as defined in section 3000.
``(f) Coordination.--The Center shall coordinate its
activities with activities conducted by the Center for
Medicare and Medicaid Innovation established under section
1115A of the Social Security Act.
``(g) Funding.--There is authorized to be appropriated to
carry out this section $20,000,000 for fiscal years 2010
through 2014.
``SEC. 934. QUALITY IMPROVEMENT TECHNICAL ASSISTANCE AND
IMPLEMENTATION.
``(a) In General.--The Director, through the Center for
Quality Improvement and Patient Safety of the Agency for
Healthcare Research and Quality (referred to in this section
as the `Center'), shall award--
``(1) technical assistance grants or contracts to eligible
entities to provide technical support to institutions that
deliver health care and health care providers (including
rural and urban providers of services and suppliers with
limited infrastructure and financial resources to implement
and support quality improvement activities, providers of
services and suppliers with poor performance scores, and
providers of services and suppliers for which there are
disparities in care among subgroups of patients) so that such
institutions and providers understand, adapt, and implement
the models and practices identified in the research conducted
by the Center, including the Quality Improvement Networks
Research Program; and
``(2) implementation grants or contracts to eligible
entities to implement the models and practices described
under paragraph (1).
``(b) Eligible Entities.--
``(1) Technical assistance award.--To be eligible to
receive a technical assistance grant or contract under
subsection (a)(1), an entity--
``(A) may be a health care provider, health care provider
association, professional society, health care worker
organization, Indian health organization, quality improvement
organization, patient safety organization, local quality
improvement collaborative, the Joint Commission, academic
health center, university, physician-based research network,
primary care extension program established under section
399W, a Federal Indian Health Service program or a health
program operated by an Indian tribe (as defined in section 4
of the Indian Health Care Improvement Act), or any other
entity identified by the Secretary; and
``(B) shall have demonstrated expertise in providing
information and technical support and assistance to health
care providers regarding quality improvement.
``(2) Implementation award.--To be eligible to receive an
implementation grant or contract under subsection (a)(2), an
entity--
``(A) may be a hospital or other health care provider or
consortium or providers, as determined by the Secretary; and
``(B) shall have demonstrated expertise in providing
information and technical support and assistance to health
care providers regarding quality improvement.
``(c) Application.--
``(1) Technical assistance award.--To receive a technical
assistance grant or contract under subsection (a)(1), an
eligible entity shall submit an application to the Secretary
at such time, in such manner, and containing--
``(A) a plan for a sustainable business model that may
include a system of--
``(i) charging fees to institutions and providers that
receive technical support from the entity; and
``(ii) reducing or eliminating such fees for such
institutions and providers that serve low-income populations;
and
``(B) such other information as the Director may require.
``(2) Implementation award.--To receive a grant or contract
under subsection (a)(2), an eligible entity shall submit an
application to the Secretary at such time, in such manner,
and containing--
``(A) a plan for implementation of a model or practice
identified in the research conducted by the Center
including--
``(i) financial cost, staffing requirements, and timeline
for implementation; and
``(ii) pre- and projected post-implementation quality
measure performance data in targeted improvement areas
identified by the Secretary; and
``(B) such other information as the Director may require.
``(d) Matching Funds.--The Director may not award a grant
or contract under this section to an entity unless the entity
agrees that it will make available (directly or through
contributions from other public or private entities) non-
Federal contributions toward the activities to be carried out
under the grant or contract in an amount equal to $1 for each
$5 of Federal funds provided under the grant or contract.
Such non-Federal matching funds may be provided directly or
through donations from public or private entities and may be
in cash or in-kind, fairly evaluated, including plant,
equipment, or services.
``(e) Evaluation.--
``(1) In general.--The Director shall evaluate the
performance of each entity that receives a grant or contract
under this section. The evaluation of an entity shall include
a study of--
``(A) the success of such entity in achieving the
implementation, by the health care institutions and providers
assisted by such entity, of the models and practices
identified in the research conducted by the Center under
section 933;
[[Page H2022]]
``(B) the perception of the health care institutions and
providers assisted by such entity regarding the value of the
entity; and
``(C) where practicable, better patient health outcomes and
lower cost resulting from the assistance provided by such
entity.
``(2) Effect of evaluation.--Based on the outcome of the
evaluation of the entity under paragraph (1), the Director
shall determine whether to renew a grant or contract with
such entity under this section.
``(f) Coordination.--The entities that receive a grant or
contract under this section shall coordinate with health
information technology regional extension centers under
section 3012(c) and the primary care extension program
established under section 399W regarding the dissemination of
quality improvement, system delivery reform, and best
practices information.''.
SEC. 3502. ESTABLISHING COMMUNITY HEALTH TEAMS TO SUPPORT THE
PATIENT-CENTERED MEDICAL HOME.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary'') shall
establish a program to provide grants to or enter into
contracts with eligible entities to establish community-based
interdisciplinary, interprofessional teams (referred to in
this section as ``health teams'') to support primary care
practices, including obstetrics and gynecology practices,
within the hospital service areas served by the eligible
entities. Grants or contracts shall be used to--
(1) establish health teams to provide support services to
primary care providers; and
(2) provide capitated payments to primary care providers as
determined by the Secretary.
(b) Eligible Entities.--To be eligible to receive a grant
or contract under subsection (a), an entity shall--
(1)(A) be a State or State-designated entity; or
(B) be an Indian tribe or tribal organization, as defined
in section 4 of the Indian Health Care Improvement Act;
(2) submit a plan for achieving long-term financial
sustainability within 3 years;
(3) submit a plan for incorporating prevention initiatives
and patient education and care management resources into the
delivery of health care that is integrated with community-
based prevention and treatment resources, where available;
(4) ensure that the health team established by the entity
includes an interdisciplinary, interprofessional team of
health care providers, as determined by the Secretary; such
team may include medical specialists, nurses, pharmacists,
nutritionists, dieticians, social workers, behavioral and
mental health providers (including substance use disorder
prevention and treatment providers), doctors of chiropractic,
licensed complementary and alternative medicine
practitioners, and physicians' assistants;
(5) agree to provide services to eligible individuals with
chronic conditions, as described in section 1945 of the
Social Security Act (as added by section 2703), in accordance
with the payment methodology established under subsection (c)
of such section; and
(6) submit to the Secretary an application at such time, in
such manner, and containing such information as the Secretary
may require.
(c) Requirements for Health Teams.--A health team
established pursuant to a grant or contract under subsection
(a) shall--
(1) establish contractual agreements with primary care
providers to provide support services;
(2) support patient-centered medical homes, defined as a
mode of care that includes--
(A) personal physicians;
(B) whole person orientation;
(C) coordinated and integrated care;
(D) safe and high-quality care through evidence-informed
medicine, appropriate use of health information technology,
and continuous quality improvements;
(E) expanded access to care; and
(F) payment that recognizes added value from additional
components of patient-centered care;
(3) collaborate with local primary care providers and
existing State and community based resources to coordinate
disease prevention, chronic disease management, transitioning
between health care providers and settings and case
management for patients, including children, with priority
given to those amenable to prevention and with chronic
diseases or conditions identified by the Secretary;
(4) in collaboration with local health care providers,
develop and implement interdisciplinary, interprofessional
care plans that integrate clinical and community preventive
and health promotion services for patients, including
children, with a priority given to those amenable to
prevention and with chronic diseases or conditions identified
by the Secretary;
(5) incorporate health care providers, patients,
caregivers, and authorized representatives in program design
and oversight;
(6) provide support necessary for local primary care
providers to--
(A) coordinate and provide access to high-quality health
care services;
(B) coordinate and provide access to preventive and health
promotion services;
(C) provide access to appropriate specialty care and
inpatient services;
(D) provide quality-driven, cost-effective, culturally
appropriate, and patient- and family-centered health care;
(E) provide access to pharmacist-delivered medication
management services, including medication reconciliation;
(F) provide coordination of the appropriate use of
complementary and alternative (CAM) services to those who
request such services;
(G) promote effective strategies for treatment planning,
monitoring health outcomes and resource use, sharing
information, treatment decision support, and organizing care
to avoid duplication of service and other medical management
approaches intended to improve quality and value of health
care services;
(H) provide local access to the continuum of health care
services in the most appropriate setting, including access to
individuals that implement the care plans of patients and
coordinate care, such as integrative health care
practitioners;
(I) collect and report data that permits evaluation of the
success of the collaborative effort on patient outcomes,
including collection of data on patient experience of care,
and identification of areas for improvement; and
(J) establish a coordinated system of early identification
and referral for children at risk for developmental or
behavioral problems such as through the use of infolines,
health information technology, or other means as determined
by the Secretary;
(7) provide 24-hour care management and support during
transitions in care settings including--
(A) a transitional care program that provides onsite visits
from the care coordinator, assists with the development of
discharge plans and medication reconciliation upon admission
to and discharge from the hospitals, nursing home, or other
institution setting;
(B) discharge planning and counseling support to providers,
patients, caregivers, and authorized representatives;
(C) assuring that post-discharge care plans include
medication management, as appropriate;
(D) referrals for mental and behavioral health services,
which may include the use of infolines; and
(E) transitional health care needs from adolescence to
adulthood;
(8) serve as a liaison to community prevention and
treatment programs;
(9) demonstrate a capacity to implement and maintain health
information technology that meets the requirements of
certified EHR technology (as defined in section 3000 of the
Public Health Service Act (42 U.S.C. 300jj)) to facilitate
coordination among members of the applicable care team and
affiliated primary care practices; and
(10) where applicable, report to the Secretary information
on quality measures used under section 399JJ of the Public
Health Service Act.
(d) Requirement for Primary Care Providers.--A provider who
contracts with a care team shall--
(1) provide a care plan to the care team for each patient
participant;
(2) provide access to participant health records; and
(3) meet regularly with the care team to ensure integration
of care.
(e) Reporting to Secretary.--An entity that receives a
grant or contract under subsection (a) shall submit to the
Secretary a report that describes and evaluates, as requested
by the Secretary, the activities carried out by the entity
under subsection (c).
(f) Definition of Primary Care.--In this section, the term
``primary care'' means the provision of integrated,
accessible health care services by clinicians who are
accountable for addressing a large majority of personal
health care needs, developing a sustained partnership with
patients, and practicing in the context of family and
community.
SEC. 3503. MEDICATION MANAGEMENT SERVICES IN TREATMENT OF
CHRONIC DISEASE.
Title IX of the Public Health Service Act (42 U.S.C. 299 et
seq.), as amended by section 3501, is further amended by
inserting after section 934 the following:
``SEC. 935. GRANTS OR CONTRACTS TO IMPLEMENT MEDICATION
MANAGEMENT SERVICES IN TREATMENT OF CHRONIC
DISEASES.
``(a) In General.--The Secretary, acting through the
Patient Safety Research Center established in section 933
(referred to in this section as the `Center'), shall
establish a program to provide grants or contracts to
eligible entities to implement medication management
(referred to in this section as `MTM') services provided by
licensed pharmacists, as a collaborative, multidisciplinary,
inter-professional approach to the treatment of chronic
diseases for targeted individuals, to improve the quality of
care and reduce overall cost in the treatment of such
diseases. The Secretary shall commence the program under this
section not later than May 1, 2010.
``(b) Eligible Entities.--To be eligible to receive a grant
or contract under subsection (a), an entity shall--
``(1) provide a setting appropriate for MTM services, as
recommended by the experts described in subsection (e);
``(2) submit to the Secretary a plan for achieving long-
term financial sustainability;
``(3) where applicable, submit a plan for coordinating MTM
services through local community health teams established in
section 3502 of the Patient Protection and Affordable Care
Act or in collaboration with primary care extension programs
established in section 399W;
``(4) submit a plan for meeting the requirements under
subsection (c); and
``(5) submit to the Secretary such other information as the
Secretary may require.
``(c) MTM Services to Targeted Individuals.--The MTM
services provided with the assistance of a grant or contract
awarded under subsection (a) shall, as allowed by State law
including applicable collaborative pharmacy practice
agreements, include--
``(1) performing or obtaining necessary assessments of the
health and functional status of each patient receiving such
MTM services;
``(2) formulating a medication treatment plan according to
therapeutic goals agreed upon by the prescriber and the
patient or caregiver or authorized representative of the
patient;
``(3) selecting, initiating, modifying, recommending
changes to, or administering medication therapy;
[[Page H2023]]
``(4) monitoring, which may include access to, ordering, or
performing laboratory assessments, and evaluating the
response of the patient to therapy, including safety and
effectiveness;
``(5) performing an initial comprehensive medication review
to identify, resolve, and prevent medication-related
problems, including adverse drug events, quarterly targeted
medication reviews for ongoing monitoring, and additional
followup interventions on a schedule developed
collaboratively with the prescriber;
``(6) documenting the care delivered and communicating
essential information about such care, including a summary of
the medication review, and the recommendations of the
pharmacist to other appropriate health care providers of the
patient in a timely fashion;
``(7) providing education and training designed to enhance
the understanding and appropriate use of the medications by
the patient, caregiver, and other authorized representative;
``(8) providing information, support services, and
resources and strategies designed to enhance patient
adherence with therapeutic regimens;
``(9) coordinating and integrating MTM services within the
broader health care management services provided to the
patient; and
``(10) such other patient care services allowed under
pharmacist scopes of practice in use in other Federal
programs that have implemented MTM services.
``(d) Targeted Individuals.--MTM services provided by
licensed pharmacists under a grant or contract awarded under
subsection (a) shall be offered to targeted individuals who--
``(1) take 4 or more prescribed medications (including
over-the-counter medications and dietary supplements);
``(2) take any `high risk' medications;
``(3) have 2 or more chronic diseases, as identified by the
Secretary; or
``(4) have undergone a transition of care, or other
factors, as determined by the Secretary, that are likely to
create a high risk of medication-related problems.
``(e) Consultation With Experts.--In designing and
implementing MTM services provided under grants or contracts
awarded under subsection (a), the Secretary shall consult
with Federal, State, private, public-private, and academic
entities, pharmacy and pharmacist organizations, health care
organizations, consumer advocates, chronic disease groups,
and other stakeholders involved with the research,
dissemination, and implementation of pharmacist-delivered MTM
services, as the Secretary determines appropriate. The
Secretary, in collaboration with this group, shall determine
whether it is possible to incorporate rapid cycle process
improvement concepts in use in other Federal programs that
have implemented MTM services.
``(f) Reporting to the Secretary.--An entity that receives
a grant or contract under subsection (a) shall submit to the
Secretary a report that describes and evaluates, as requested
by the Secretary, the activities carried out under subsection
(c), including quality measures endorsed by the entity with a
contract under section 1890 of the Social Security Act, as
determined by the Secretary.
``(g) Evaluation and Report.--The Secretary shall submit to
the relevant committees of Congress a report which shall--
``(1) assess the clinical effectiveness of pharmacist-
provided services under the MTM services program, as compared
to usual care, including an evaluation of whether enrollees
maintained better health with fewer hospitalizations and
emergency room visits than similar patients not enrolled in
the program;
``(2) assess changes in overall health care resource use by
targeted individuals;
``(3) assess patient and prescriber satisfaction with MTM
services;
``(4) assess the impact of patient-cost sharing
requirements on medication adherence and recommendations for
modifications;
``(5) identify and evaluate other factors that may impact
clinical and economic outcomes, including demographic
characteristics, clinical characteristics, and health
services use of the patient, as well as characteristics of
the regimen, pharmacy benefit, and MTM services provided; and
``(6) evaluate the extent to which participating
pharmacists who maintain a dispensing role have a conflict of
interest in the provision of MTM services, and if such
conflict is found, provide recommendations on how such a
conflict might be appropriately addressed.
``(h) Grants or Contracts To Fund Development of
Performance Measures.--The Secretary may, through the quality
measure development program under section 931 of the Public
Health Service Act, award grants or contracts to eligible
entities for the purpose of funding the development of
performance measures that assess the use and effectiveness of
medication therapy management services.''.
SEC. 3504. DESIGN AND IMPLEMENTATION OF REGIONALIZED SYSTEMS
FOR EMERGENCY CARE.
(a) In General.--Title XII of the Public Health Service Act
(42 U.S.C. 300d et seq.) is amended--
(1) in section 1203--
(A) in the section heading, by inserting ``FOR TRAUMA
SYSTEMS'' after ``GRANTS''; and
(B) in subsection (a), by striking ``Administrator of the
Health Resources and Services Administration'' and inserting
``Assistant Secretary for Preparedness and Response'';
(2) by inserting after section 1203 the following:
``SEC. 1204. COMPETITIVE GRANTS FOR REGIONALIZED SYSTEMS FOR
EMERGENCY CARE RESPONSE.
``(a) In General.--The Secretary, acting through the
Assistant Secretary for Preparedness and Response, shall
award not fewer than 4 multiyear contracts or competitive
grants to eligible entities to support pilot projects that
design, implement, and evaluate innovative models of
regionalized, comprehensive, and accountable emergency care
and trauma systems.
``(b) Eligible Entity; Region.--In this section:
``(1) Eligible entity.--The term `eligible entity' means--
``(A) a State or a partnership of 1 or more States and 1 or
more local governments; or
``(B) an Indian tribe (as defined in section 4 of the
Indian Health Care Improvement Act) or a partnership of 1 or
more Indian tribes.
``(2) Region.--The term `region' means an area within a
State, an area that lies within multiple States, or a similar
area (such as a multicounty area), as determined by the
Secretary.
``(3) Emergency services.--The term `emergency services'
includes acute, prehospital, and trauma care.
``(c) Pilot Projects.--The Secretary shall award a contract
or grant under subsection (a) to an eligible entity that
proposes a pilot project to design, implement, and evaluate
an emergency medical and trauma system that--
``(1) coordinates with public health and safety services,
emergency medical services, medical facilities, trauma
centers, and other entities in a region to develop an
approach to emergency medical and trauma system access
throughout the region, including 9-1-1 Public Safety
Answering Points and emergency medical dispatch;
``(2) includes a mechanism, such as a regional medical
direction or transport communications system, that operates
throughout the region to ensure that the patient is taken to
the medically appropriate facility (whether an initial
facility or a higher-level facility) in a timely fashion;
``(3) allows for the tracking of prehospital and hospital
resources, including inpatient bed capacity, emergency
department capacity, trauma center capacity, on-call
specialist coverage, ambulance diversion status, and the
coordination of such tracking with regional communications
and hospital destination decisions; and
``(4) includes a consistent region-wide prehospital,
hospital, and interfacility data management system that--
``(A) submits data to the National EMS Information System,
the National Trauma Data Bank, and others;
``(B) reports data to appropriate Federal and State
databanks and registries; and
``(C) contains information sufficient to evaluate key
elements of prehospital care, hospital destination decisions,
including initial hospital and interfacility decisions, and
relevant health outcomes of hospital care.
``(d) Application.--
``(1) In general.--An eligible entity that seeks a contract
or grant described in subsection (a) shall submit to the
Secretary an application at such time and in such manner as
the Secretary may require.
``(2) Application information.--Each application shall
include--
``(A) an assurance from the eligible entity that the
proposed system--
``(i) has been coordinated with the applicable State Office
of Emergency Medical Services (or equivalent State office);
``(ii) includes consistent indirect and direct medical
oversight of prehospital, hospital, and interfacility
transport throughout the region;
``(iii) coordinates prehospital treatment and triage,
hospital destination, and interfacility transport throughout
the region;
``(iv) includes a categorization or designation system for
special medical facilities throughout the region that is
integrated with transport and destination protocols;
``(v) includes a regional medical direction, patient
tracking, and resource allocation system that supports day-
to-day emergency care and surge capacity and is integrated
with other components of the national and State emergency
preparedness system; and
``(vi) addresses pediatric concerns related to integration,
planning, preparedness, and coordination of emergency medical
services for infants, children and adolescents; and
``(B) such other information as the Secretary may require.
``(e) Requirement of Matching Funds.--
``(1) In general.--The Secretary may not make a grant under
this section unless the State (or consortia of States)
involved agrees, with respect to the costs to be incurred by
the State (or consortia) in carrying out the purpose for
which such grant was made, to make available non-Federal
contributions (in cash or in kind under paragraph (2)) toward
such costs in an amount equal to not less than $1 for each $3
of Federal funds provided in the grant. Such contributions
may be made directly or through donations from public or
private entities.
``(2) Non-federal contributions.--Non-Federal contributions
required in paragraph (1) may be in cash or in kind, fairly
evaluated, including equipment or services (and excluding
indirect or overhead costs). Amounts provided by the Federal
Government, or services assisted or subsidized to any
significant extent by the Federal Government, may not be
included in determining the amount of such non-Federal
contributions.
``(f) Priority.--The Secretary shall give priority for the
award of the contracts or grants described in subsection (a)
to any eligible entity that serves a population in a
medically underserved area (as defined in section 330(b)(3)).
``(g) Report.--Not later than 90 days after the completion
of a pilot project under subsection (a), the recipient of
such contract or grant described in shall submit to the
Secretary a report containing the results of an evaluation of
the program, including an identification of--
``(1) the impact of the regional, accountable emergency
care and trauma system on patient health outcomes for various
critical care categories, such as trauma, stroke, cardiac
emergencies, neurological emergencies, and pediatric
emergencies;
[[Page H2024]]
``(2) the system characteristics that contribute to the
effectiveness and efficiency of the program (or lack
thereof);
``(3) methods of assuring the long-term financial
sustainability of the emergency care and trauma system;
``(4) the State and local legislation necessary to
implement and to maintain the system;
``(5) the barriers to developing regionalized, accountable
emergency care and trauma systems, as well as the methods to
overcome such barriers; and
``(6) recommendations on the utilization of available
funding for future regionalization efforts.
``(h) Dissemination of Findings.--The Secretary shall, as
appropriate, disseminate to the public and to the appropriate
Committees of the Congress, the information contained in a
report made under subsection (g).''; and
(3) in section 1232--
(A) in subsection (a), by striking ``appropriated'' and all
that follows through the period at the end and inserting
``appropriated $24,000,000 for each of fiscal years 2010
through 2014.''; and
(B) by inserting after subsection (c) the following:
``(d) Authority.--For the purpose of carrying out parts A
through C, beginning on the date of enactment of the Patient
Protection and Affordable Care Act, the Secretary shall
transfer authority in administering grants and related
authorities under such parts from the Administrator of the
Health Resources and Services Administration to the Assistant
Secretary for Preparedness and Response.''.
(b) Support for Emergency Medicine Research.--Part H of
title IV of the Public Health Service Act (42 U.S.C. 289 et
seq.) is amended by inserting after the section 498C the
following:
``SEC. 498D. SUPPORT FOR EMERGENCY MEDICINE RESEARCH.
``(a) Emergency Medical Research.--The Secretary shall
support Federal programs administered by the National
Institutes of Health, the Agency for Healthcare Research and
Quality, the Health Resources and Services Administration,
the Centers for Disease Control and Prevention, and other
agencies involved in improving the emergency care system to
expand and accelerate research in emergency medical care
systems and emergency medicine, including--
``(1) the basic science of emergency medicine;
``(2) the model of service delivery and the components of
such models that contribute to enhanced patient health
outcomes;
``(3) the translation of basic scientific research into
improved practice; and
``(4) the development of timely and efficient delivery of
health services.
``(b) Pediatric Emergency Medical Research.--The Secretary
shall support Federal programs administered by the National
Institutes of Health, the Agency for Healthcare Research and
Quality, the Health Resources and Services Administration,
the Centers for Disease Control and Prevention, and other
agencies to coordinate and expand research in pediatric
emergency medical care systems and pediatric emergency
medicine, including--
``(1) an examination of the gaps and opportunities in
pediatric emergency care research and a strategy for the
optimal organization and funding of such research;
``(2) the role of pediatric emergency services as an
integrated component of the overall health system;
``(3) system-wide pediatric emergency care planning,
preparedness, coordination, and funding;
``(4) pediatric training in professional education; and
``(5) research in pediatric emergency care, specifically on
the efficacy, safety, and health outcomes of medications used
for infants, children, and adolescents in emergency care
settings in order to improve patient safety.
``(c) Impact Research.--The Secretary shall support
research to determine the estimated economic impact of, and
savings that result from, the implementation of coordinated
emergency care systems.
``(d) Authorization of Appropriations.--There are
authorized to be appropriated to carry out this section such
sums as may be necessary for each of fiscal years 2010
through 2014.''.
SEC. 3505. TRAUMA CARE CENTERS AND SERVICE AVAILABILITY.
(a) Trauma Care Centers.--
(1) Grants for trauma care centers.--Section 1241 of the
Public Health Service Act (42 U.S.C. 300d-41) is amended by
striking subsections (a) and (b) and inserting the following:
``(a) In General.--The Secretary shall establish 3 programs
to award grants to qualified public, nonprofit Indian Health
Service, Indian tribal, and urban Indian trauma centers--
``(1) to assist in defraying substantial uncompensated care
costs;
``(2) to further the core missions of such trauma centers,
including by addressing costs associated with patient
stabilization and transfer, trauma education and outreach,
coordination with local and regional trauma systems,
essential personnel and other fixed costs, and expenses
associated with employee and non-employee physician services;
and
``(3) to provide emergency relief to ensure the continued
and future availability of trauma services.
``(b) Minimum Qualifications of Trauma Centers.--
``(1) Participation in trauma care system operating under
certain professional guidelines.--Except as provided in
paragraph (2), the Secretary may not award a grant to a
trauma center under subsection (a) unless the trauma center
is a participant in a trauma system that substantially
complies with section 1213.
``(2) Exemption.--Paragraph (1) shall not apply to trauma
centers that are located in States with no existing trauma
care system.
``(3) Qualification for substantial uncompensated care
costs.--The Secretary shall award substantial uncompensated
care grants under subsection (a)(1) only to trauma centers
meeting at least 1 of the criteria in 1 of the following 3
categories:
``(A) Category a.--The criteria for category A are as
follows:
``(i) At least 40 percent of the visits in the emergency
department of the hospital in which the trauma center is
located were charity or self-pay patients.
``(ii) At least 50 percent of the visits in such emergency
department were Medicaid (under title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.)) and charity and self-
pay patients combined.
``(B) Category b.--The criteria for category B are as
follows:
``(i) At least 35 percent of the visits in the emergency
department were charity or self-pay patients.
``(ii) At least 50 percent of the visits in the emergency
department were Medicaid and charity and self-pay patients
combined.
``(C) Category c.--The criteria for category C are as
follows:
``(i) At least 20 percent of the visits in the emergency
department were charity or self-pay patients.
``(ii) At least 30 percent of the visits in the emergency
department were Medicaid and charity and self-pay patients
combined.
``(4) Trauma centers in 1115 waiver states.--
Notwithstanding paragraph (3), the Secretary may award a
substantial uncompensated care grant to a trauma center under
subsection (a)(1) if the trauma center qualifies for funds
under a Low Income Pool or Safety Net Care Pool established
through a waiver approved under section 1115 of the Social
Security Act (42 U.S.C. 1315).
``(5) Designation.--The Secretary may not award a grant to
a trauma center unless such trauma center is verified by the
American College of Surgeons or designated by an equivalent
State or local agency.
``(c) Additional Requirements.--The Secretary may not award
a grant to a trauma center under subsection (a)(1) unless
such trauma center--
``(1) submits to the Secretary a plan satisfactory to the
Secretary that demonstrates a continued commitment to serving
trauma patients regardless of their ability to pay; and
``(2) has policies in place to assist patients who cannot
pay for part or all of the care they receive, including a
sliding fee scale, and to ensure fair billing and collection
practices.''.
(2) Considerations in making grants.--Section 1242 of the
Public Health Service Act (42 U.S.C. 300d-42) is amended by
striking subsections (a) and (b) and inserting the following:
``(a) Substantial Uncompensated Care Awards.--
``(1) In general.--The Secretary shall establish an award
basis for each eligible trauma center for grants under
section 1241(a)(1) according to the percentage described in
paragraph (2), subject to the requirements of section
1241(b)(3).
``(2) Percentages.--The applicable percentages are as
follows:
``(A) With respect to a category A trauma center, 100
percent of the uncompensated care costs.
``(B) With respect to a category B trauma center, not more
than 75 percent of the uncompensated care costs.
``(C) With respect to a category C trauma center, not more
than 50 percent of the uncompensated care costs.
``(b) Core Mission Awards.--
``(1) In general.--In awarding grants under section
1241(a)(2), the Secretary shall--
``(A) reserve 25 percent of the amount allocated for core
mission awards for Level III and Level IV trauma centers; and
``(B) reserve 25 percent of the amount allocated for core
mission awards for large urban Level I and II trauma
centers--
``(i) that have at least 1 graduate medical education
fellowship in trauma or trauma related specialties for which
demand is exceeding supply;
``(ii) for which--
``(I) annual uncompensated care costs exceed $10,000,000;
or
``(II) at least 20 percent of emergency department visits
are charity or self-pay or Medicaid patients; and
``(iii) that are not eligible for substantial uncompensated
care awards under section 1241(a)(1).
``(c) Emergency Awards.--In awarding grants under section
1241(a)(3), the Secretary shall--
``(1) give preference to any application submitted by a
trauma center that provides trauma care in a geographic area
in which the availability of trauma care has significantly
decreased or will significantly decrease if the center is
forced to close or downgrade service or growth in demand for
trauma services exceeds capacity; and
``(2) reallocate any emergency awards funds not obligated
due to insufficient, or a lack of qualified, applications to
the significant uncompensated care award program.''.
(3) Certain agreements.--Section 1243 of the Public Health
Service Act (42 U.S.C. 300d-43) is amended by striking
subsections (a), (b), and (c) and inserting the following:
``(a) Maintenance of Financial Support.--The Secretary may
require a trauma center receiving a grant under section
1241(a) to maintain access to trauma services at comparable
levels to the prior year during the grant period.
``(b) Trauma Care Registry.--The Secretary may require the
trauma center receiving a grant under section 1241(a) to
provide data to a national and centralized registry of trauma
cases, in accordance with guidelines developed by the
American College of Surgeons, and as the Secretary may
otherwise require.''.
[[Page H2025]]
(4) General provisions.--Section 1244 of the Public Health
Service Act (42 U.S.C. 300d-44) is amended by striking
subsections (a), (b), and (c) and inserting the following:
``(a) Application.--The Secretary may not award a grant to
a trauma center under section 1241(a) unless such center
submits an application for the grant to the Secretary and the
application is in such form, is made in such manner, and
contains such agreements, assurances, and information as the
Secretary determines to be necessary to carry out this part.
``(b) Limitation on Duration of Support.--The period during
which a trauma center receives payments under a grant under
section 1241(a)(3) shall be for 3 fiscal years, except that
the Secretary may waive such requirement for a center and
authorize such center to receive such payments for 1
additional fiscal year.
``(c) Limitation on Amount of Grant.--Notwithstanding
section 1242(a), a grant under section 1241 may not be made
in an amount exceeding $2,000,000 for each fiscal year.
``(d) Eligibility.--Except as provided in section
1242(b)(1)(B)(iii), acquisition of, or eligibility for, a
grant under section 1241(a) shall not preclude a trauma
center from being eligible for other grants described in such
section.
``(e) Funding Distribution.--Of the total amount
appropriated for a fiscal year under section 1245, 70 percent
shall be used for substantial uncompensated care awards under
section 1241(a)(1), 20 percent shall be used for core mission
awards under section 1241(a)(2), and 10 percent shall be used
for emergency awards under section 1241(a)(3).
``(f) Minimum Allowance.--Notwithstanding subsection (e),
if the amount appropriated for a fiscal year under section
1245 is less than $25,000,000, all available funding for such
fiscal year shall be used for substantial uncompensated care
awards under section 1241(a)(1).
``(g) Substantial Uncompensated Care Award Distribution and
Proportional Share.--Notwithstanding section 1242(a), of the
amount appropriated for substantial uncompensated care grants
for a fiscal year, the Secretary shall--
``(1) make available--
``(A) 50 percent of such funds for category A trauma center
grantees;
``(B) 35 percent of such funds for category B trauma center
grantees; and
``(C) 15 percent of such funds for category C trauma center
grantees; and
``(2) provide available funds within each category in a
manner proportional to the award basis specified in section
1242(a)(2) to each eligible trauma center.
``(h) Report.--Beginning 2 years after the date of
enactment of the Patient Protection and Affordable Care Act,
and every 2 years thereafter, the Secretary shall biennially
report to Congress regarding the status of the grants made
under section 1241 and on the overall financial stability of
trauma centers.''.
(5) Authorization of appropriations.--Section 1245 of the
Public Health Service Act (42 U.S.C. 300d-45) is amended to
read as follows:
``SEC. 1245. AUTHORIZATION OF APPROPRIATIONS.
``For the purpose of carrying out this part, there are
authorized to be appropriated $100,000,000 for fiscal year
2009, and such sums as may be necessary for each of fiscal
years 2010 through 2015. Such authorization of appropriations
is in addition to any other authorization of appropriations
or amounts that are available for such purpose.''.
(6) Definition.--Part D of title XII of the Public Health
Service Act (42 U.S.C. 300d-41 et seq.) is amended by adding
at the end the following:
``SEC. 1246. DEFINITION.
``In this part, the term `uncompensated care costs' means
unreimbursed costs from serving self-pay, charity, or
Medicaid patients, without regard to payment under section
1923 of the Social Security Act, all of which are
attributable to emergency care and trauma care, including
costs related to subsequent inpatient admissions to the
hospital.''.
(b) Trauma Service Availability.--Title XII of the Public
Health Service Act (42 U.S.C. 300d et seq.) is amended by
adding at the end the following:
``PART H--TRAUMA SERVICE AVAILABILITY
``SEC. 1281. GRANTS TO STATES.
``(a) Establishment.--To promote universal access to trauma
care services provided by trauma centers and trauma-related
physician specialties, the Secretary shall provide funding to
States to enable such States to award grants to eligible
entities for the purposes described in this section.
``(b) Awarding of Grants by States.--Each State may award
grants to eligible entities within the State for the purposes
described in subparagraph (d).
``(c) Eligibility.--
``(1) In general.--To be eligible to receive a grant under
subsection (b) an entity shall--
``(A) be--
``(i) a public or nonprofit trauma center or consortium
thereof that meets that requirements of paragraphs (1), (2),
and (5) of section 1241(b);
``(ii) a safety net public or nonprofit trauma center that
meets the requirements of paragraphs (1) through (5) of
section 1241(b); or
``(iii) a hospital in an underserved area (as defined by
the State) that seeks to establish new trauma services; and
``(B) submit to the State an application at such time, in
such manner, and containing such information as the State may
require.
``(2) Limitation.--A State shall use at least 40 percent of
the amount available to the State under this part for a
fiscal year to award grants to safety net trauma centers
described in paragraph (1)(A)(ii).
``(d) Use of Funds.--The recipient of a grant under
subsection (b) shall carry out 1 or more of the following
activities consistent with subsection (b):
``(1) Providing trauma centers with funding to support
physician compensation in trauma-related physician
specialties where shortages exist in the region involved,
with priority provided to safety net trauma centers described
in subsection (c)(1)(A)(ii).
``(2) Providing for individual safety net trauma center
fiscal stability and costs related to having service that is
available 24 hours a day, 7 days a week, with priority
provided to safety net trauma centers described in subsection
(c)(1)(A)(ii) located in urban, border, and rural areas.
``(3) Reducing trauma center overcrowding at specific
trauma centers related to throughput of trauma patients.
``(4) Establishing new trauma services in underserved areas
as defined by the State.
``(5) Enhancing collaboration between trauma centers and
other hospitals and emergency medical services personnel
related to trauma service availability.
``(6) Making capital improvements to enhance access and
expedite trauma care, including providing helipads and
associated safety infrastructure.
``(7) Enhancing trauma surge capacity at specific trauma
centers.
``(8) Ensuring expedient receipt of trauma patients
transported by ground or air to the appropriate trauma
center.
``(9) Enhancing interstate trauma center collaboration.
``(e) Limitation.--
``(1) In general.--A State may use not more than 20 percent
of the amount available to the State under this part for a
fiscal year for administrative costs associated with awarding
grants and related costs.
``(2) Maintenance of effort.--The Secretary may not provide
funding to a State under this part unless the State agrees
that such funds will be used to supplement and not supplant
State funding otherwise available for the activities and
costs described in this part.
``(f) Distribution of Funds.--The following shall apply
with respect to grants provided in this part:
``(1) Less than $10,000,000.--If the amount of
appropriations for this part in a fiscal year is less than
$10,000,000, the Secretary shall divide such funding evenly
among only those States that have 1 or more trauma centers
eligible for funding under section 1241(b)(3)(A).
``(2) Less than $20,000,000.--If the amount of
appropriations in a fiscal year is less than $20,000,000, the
Secretary shall divide such funding evenly among only those
States that have 1 or more trauma centers eligible for
funding under subparagraphs (A) and (B) of section
1241(b)(3).
``(3) Less than $30,000,000.--If the amount of
appropriations for this part in a fiscal year is less than
$30,000,000, the Secretary shall divide such funding evenly
among only those States that have 1 or more trauma centers
eligible for funding under section 1241(b)(3).
``(4) $30,000,000 or more.--If the amount of appropriations
for this part in a fiscal year is $30,000,000 or more, the
Secretary shall divide such funding evenly among all States.
``SEC. 1282. AUTHORIZATION OF APPROPRIATIONS.
``For the purpose of carrying out this part, there is
authorized to be appropriated $100,000,000 for each of fiscal
years 2010 through 2015.''.
SEC. 3506. PROGRAM TO FACILITATE SHARED DECISIONMAKING.
Part D of title IX of the Public Health Service Act, as
amended by section 3503, is further amended by adding at the
end the following:
``SEC. 936. PROGRAM TO FACILITATE SHARED DECISIONMAKING.
``(a) Purpose.--The purpose of this section is to
facilitate collaborative processes between patients,
caregivers or authorized representatives, and clinicians that
engages the patient, caregiver or authorized representative
in decisionmaking, provides patients, caregivers or
authorized representatives with information about trade-offs
among treatment options, and facilitates the incorporation of
patient preferences and values into the medical plan.
``(b) Definitions.--In this section:
``(1) Patient decision aid.--The term `patient decision
aid' means an educational tool that helps patients,
caregivers or authorized representatives understand and
communicate their beliefs and preferences related to their
treatment options, and to decide with their health care
provider what treatments are best for them based on their
treatment options, scientific evidence, circumstances,
beliefs, and preferences.
``(2) Preference sensitive care.--The term `preference
sensitive care' means medical care for which the clinical
evidence does not clearly support one treatment option such
that the appropriate course of treatment depends on the
values of the patient or the preferences of the patient,
caregivers or authorized representatives regarding the
benefits, harms and scientific evidence for each treatment
option, the use of such care should depend on the informed
patient choice among clinically appropriate treatment
options.
``(c) Establishment of Independent Standards for Patient
Decision Aids for Preference Sensitive Care.--
``(1) Contract with entity to establish standards and
certify patient decision aids.--
``(A) In general.--For purposes of supporting consensus-
based standards for patient decision aids for preference
sensitive care and a certification process for patient
decision aids for use in the Federal health programs and by
other interested parties, the Secretary shall have in effect
a contract with the entity with a contract
[[Page H2026]]
under section 1890 of the Social Security Act. Such contract
shall provide that the entity perform the duties described in
paragraph (2).
``(B) Timing for first contract.--As soon as practicable
after the date of the enactment of this section, the
Secretary shall enter into the first contract under
subparagraph (A).
``(C) Period of contract.--A contract under subparagraph
(A) shall be for a period of 18 months (except such contract
may be renewed after a subsequent bidding process).
``(2) Duties.--The following duties are described in this
paragraph:
``(A) Develop and identify standards for patient decision
aids.--The entity shall synthesize evidence and convene a
broad range of experts and key stakeholders to develop and
identify consensus-based standards to evaluate patient
decision aids for preference sensitive care.
``(B) Endorse patient decision aids.--The entity shall
review patient decision aids and develop a certification
process whether patient decision aids meet the standards
developed and identified under subparagraph (A). The entity
shall give priority to the review and certification of
patient decision aids for preference sensitive care.
``(d) Program To Develop, Update and Patient Decision Aids
To Assist Health Care Providers and Patients.--
``(1) In general.--The Secretary, acting through the
Director, and in coordination with heads of other relevant
agencies, such as the Director of the Centers for Disease
Control and Prevention and the Director of the National
Institutes of Health, shall establish a program to award
grants or contracts--
``(A) to develop, update, and produce patient decision aids
for preference sensitive care to assist health care providers
in educating patients, caregivers, and authorized
representatives concerning the relative safety, relative
effectiveness (including possible health outcomes and impact
on functional status), and relative cost of treatment or,
where appropriate, palliative care options;
``(B) to test such materials to ensure such materials are
balanced and evidence based in aiding health care providers
and patients, caregivers, and authorized representatives to
make informed decisions about patient care and can be easily
incorporated into a broad array of practice settings; and
``(C) to educate providers on the use of such materials,
including through academic curricula.
``(2) Requirements for patient decision aids.--Patient
decision aids developed and produced pursuant to a grant or
contract under paragraph (1)--
``(A) shall be designed to engage patients, caregivers, and
authorized representatives in informed decisionmaking with
health care providers;
``(B) shall present up-to-date clinical evidence about the
risks and benefits of treatment options in a form and manner
that is age-appropriate and can be adapted for patients,
caregivers, and authorized representatives from a variety of
cultural and educational backgrounds to reflect the varying
needs of consumers and diverse levels of health literacy;
``(C) shall, where appropriate, explain why there is a lack
of evidence to support one treatment option over another; and
``(D) shall address health care decisions across the age
span, including those affecting vulnerable populations
including children.
``(3) Distribution.--The Director shall ensure that patient
decision aids produced with grants or contracts under this
section are available to the public.
``(4) Nonduplication of efforts.--The Director shall ensure
that the activities under this section of the Agency and
other agencies, including the Centers for Disease Control and
Prevention and the National Institutes of Health, are free of
unnecessary duplication of effort.
``(e) Grants To Support Shared Decisionmaking
Implementation.--
``(1) In general.--The Secretary shall establish a program
to provide for the phased-in development, implementation, and
evaluation of shared decisionmaking using patient decision
aids to meet the objective of improving the understanding of
patients of their medical treatment options.
``(2) Shared decisionmaking resource centers.--
``(A) In general.--The Secretary shall provide grants for
the establishment and support of Shared Decisionmaking
Resource Centers (referred to in this subsection as
`Centers') to provide technical assistance to providers and
to develop and disseminate best practices and other
information to support and accelerate adoption,
implementation, and effective use of patient decision aids
and shared decisionmaking by providers.
``(B) Objectives.--The objective of a Center is to enhance
and promote the adoption of patient decision aids and shared
decisionmaking through--
``(i) providing assistance to eligible providers with the
implementation and effective use of, and training on, patient
decision aids; and
``(ii) the dissemination of best practices and research on
the implementation and effective use of patient decision
aids.
``(3) Shared decisionmaking participation grants.--
``(A) In general.--The Secretary shall provide grants to
health care providers for the development and implementation
of shared decisionmaking techniques and to assess the use of
such techniques.
``(B) Preference.--In order to facilitate the use of best
practices, the Secretary shall provide a preference in making
grants under this subsection to health care providers who
participate in training by Shared Decisionmaking Resource
Centers or comparable training.
``(C) Limitation.--Funds under this paragraph shall not be
used to purchase or implement use of patient decision aids
other than those certified under the process identified in
subsection (c).
``(4) Guidance.--The Secretary may issue guidance to
eligible grantees under this subsection on the use of patient
decision aids.
``(f) Funding.--For purposes of carrying out this section
there are authorized to be appropriated such sums as may be
necessary for fiscal year 2010 and each subsequent fiscal
year.''.
SEC. 3507. PRESENTATION OF PRESCRIPTION DRUG BENEFIT AND RISK
INFORMATION.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary''), acting
through the Commissioner of Food and Drugs, shall determine
whether the addition of quantitative summaries of the
benefits and risks of prescription drugs in a standardized
format (such as a table or drug facts box) to the promotional
labeling or print advertising of such drugs would improve
health care decisionmaking by clinicians and patients and
consumers.
(b) Review and Consultation.--In making the determination
under subsection (a), the Secretary shall review all
available scientific evidence and research on decisionmaking
and social and cognitive psychology and consult with drug
manufacturers, clinicians, patients and consumers, experts in
health literacy, representatives of racial and ethnic
minorities, and experts in women's and pediatric health.
(c) Report.--Not later than 1 year after the date of
enactment of this Act, the Secretary shall submit to Congress
a report that provides--
(1) the determination by the Secretary under subsection
(a); and
(2) the reasoning and analysis underlying that
determination.
(d) Authority.--If the Secretary determines under
subsection (a) that the addition of quantitative summaries of
the benefits and risks of prescription drugs in a
standardized format (such as a table or drug facts box) to
the promotional labeling or print advertising of such drugs
would improve health care decisionmaking by clinicians and
patients and consumers, then the Secretary, not later than 3
years after the date of submission of the report under
subsection (c), shall promulgate proposed regulations as
necessary to implement such format.
(e) Clarification.--Nothing in this section shall be
construed to restrict the existing authorities of the
Secretary with respect to benefit and risk information.
SEC. 3508. DEMONSTRATION PROGRAM TO INTEGRATE QUALITY
IMPROVEMENT AND PATIENT SAFETY TRAINING INTO
CLINICAL EDUCATION OF HEALTH PROFESSIONALS.
(a) In General.--The Secretary may award grants to eligible
entities or consortia under this section to carry out
demonstration projects to develop and implement academic
curricula that integrates quality improvement and patient
safety in the clinical education of health professionals.
Such awards shall be made on a competitive basis and pursuant
to peer review.
(b) Eligibility.--To be eligible to receive a grant under
subsection (a), an entity or consortium shall--
(1) submit to the Secretary an application at such time, in
such manner, and containing such information as the Secretary
may require;
(2) be or include--
(A) a health professions school;
(B) a school of public health;
(C) a school of social work;
(D) a school of nursing;
(E) a school of pharmacy;
(F) an institution with a graduate medical education
program; or
(G) a school of health care administration;
(3) collaborate in the development of curricula described
in subsection (a) with an organization that accredits such
school or institution;
(4) provide for the collection of data regarding the
effectiveness of the demonstration project; and
(5) provide matching funds in accordance with subsection
(c).
(c) Matching Funds.--
(1) In general.--The Secretary may award a grant to an
entity or consortium under this section only if the entity or
consortium agrees to make available non-Federal contributions
toward the costs of the program to be funded under the grant
in an amount that is not less than $1 for each $5 of Federal
funds provided under the grant.
(2) Determination of amount contributed.--Non-Federal
contributions under paragraph (1) may be in cash or in-kind,
fairly evaluated, including equipment or services. Amounts
provided by the Federal Government, or services assisted or
subsidized to any significant extent by the Federal
Government, may not be included in determining the amount of
such contributions.
(d) Evaluation.--The Secretary shall take such action as
may be necessary to evaluate the projects funded under this
section and publish, make publicly available, and disseminate
the results of such evaluations on as wide a basis as is
practicable.
(e) Reports.--Not later than 2 years after the date of
enactment of this section, and annually thereafter, the
Secretary shall submit to the Committee on Health, Education,
Labor, and Pensions and the Committee on Finance of the
Senate and the Committee on Energy and Commerce and the
Committee on Ways and Means of the House of Representatives a
report that--
(1) describes the specific projects supported under this
section; and
(2) contains recommendations for Congress based on the
evaluation conducted under subsection (d).
[[Page H2027]]
SEC. 3509. IMPROVING WOMEN'S HEALTH.
(a) Health and Human Services Office on Women's Health.--
(1) Establishment.--Part A of title II of the Public Health
Service Act (42 U.S.C. 202 et seq.) is amended by adding at
the end the following:
``SEC. 229. HEALTH AND HUMAN SERVICES OFFICE ON WOMEN'S
HEALTH.
``(a) Establishment of Office.--There is established within
the Office of the Secretary, an Office on Women's Health
(referred to in this section as the `Office'). The Office
shall be headed by a Deputy Assistant Secretary for Women's
Health who may report to the Secretary.
``(b) Duties.--The Secretary, acting through the Office,
with respect to the health concerns of women, shall--
``(1) establish short-range and long-range goals and
objectives within the Department of Health and Human Services
and, as relevant and appropriate, coordinate with other
appropriate offices on activities within the Department that
relate to disease prevention, health promotion, service
delivery, research, and public and health care professional
education, for issues of particular concern to women
throughout their lifespan;
``(2) provide expert advice and consultation to the
Secretary concerning scientific, legal, ethical, and policy
issues relating to women's health;
``(3) monitor the Department of Health and Human Services'
offices, agencies, and regional activities regarding women's
health and identify needs regarding the coordination of
activities, including intramural and extramural
multidisciplinary activities;
``(4) establish a Department of Health and Human Services
Coordinating Committee on Women's Health, which shall be
chaired by the Deputy Assistant Secretary for Women's Health
and composed of senior level representatives from each of the
agencies and offices of the Department of Health and Human
Services;
``(5) establish a National Women's Health Information
Center to--
``(A) facilitate the exchange of information regarding
matters relating to health information, health promotion,
preventive health services, research advances, and education
in the appropriate use of health care;
``(B) facilitate access to such information;
``(C) assist in the analysis of issues and problems
relating to the matters described in this paragraph; and
``(D) provide technical assistance with respect to the
exchange of information (including facilitating the
development of materials for such technical assistance);
``(6) coordinate efforts to promote women's health programs
and policies with the private sector; and
``(7) through publications and any other means appropriate,
provide for the exchange of information between the Office
and recipients of grants, contracts, and agreements under
subsection (c), and between the Office and health
professionals and the general public.
``(c) Grants and Contracts Regarding Duties.--
``(1) Authority.--In carrying out subsection (b), the
Secretary may make grants to, and enter into cooperative
agreements, contracts, and interagency agreements with,
public and private entities, agencies, and organizations.
``(2) Evaluation and dissemination.--The Secretary shall
directly or through contracts with public and private
entities, agencies, and organizations, provide for
evaluations of projects carried out with financial assistance
provided under paragraph (1) and for the dissemination of
information developed as a result of such projects.
``(d) Reports.--Not later than 1 year after the date of
enactment of this section, and every second year thereafter,
the Secretary shall prepare and submit to the appropriate
committees of Congress a report describing the activities
carried out under this section during the period for which
the report is being prepared.
``(e) Authorization of Appropriations.--For the purpose of
carrying out this section, there are authorized to be
appropriated such sums as may be necessary for each of the
fiscal years 2010 through 2014.''.
(2) Transfer of functions.--There are transferred to the
Office on Women's Health (established under section 229 of
the Public Health Service Act, as added by this section), all
functions exercised by the Office on Women's Health of the
Public Health Service prior to the date of enactment of this
section, including all personnel and compensation authority,
all delegation and assignment authority, and all remaining
appropriations. All orders, determinations, rules,
regulations, permits, agreements, grants, contracts,
certificates, licenses, registrations, privileges, and other
administrative actions that--
(A) have been issued, made, granted, or allowed to become
effective by the President, any Federal agency or official
thereof, or by a court of competent jurisdiction, in the
performance of functions transferred under this paragraph;
and
(B) are in effect at the time this section takes effect, or
were final before the date of enactment of this section and
are to become effective on or after such date,
shall continue in effect according to their terms until
modified, terminated, superseded, set aside, or revoked in
accordance with law by the President, the Secretary, or other
authorized official, a court of competent jurisdiction, or by
operation of law.
(b) Centers for Disease Control and Prevention Office of
Women's Health.--Part A of title III of the Public Health
Service Act (42 U.S.C. 241 et seq.) is amended by adding at
the end the following:
``SEC. 310A. CENTERS FOR DISEASE CONTROL AND PREVENTION
OFFICE OF WOMEN'S HEALTH.
``(a) Establishment.--There is established within the
Office of the Director of the Centers for Disease Control and
Prevention, an office to be known as the Office of Women's
Health (referred to in this section as the `Office'). The
Office shall be headed by a director who shall be appointed
by the Director of such Centers.
``(b) Purpose.--The Director of the Office shall--
``(1) report to the Director of the Centers for Disease
Control and Prevention on the current level of the Centers'
activity regarding women's health conditions across, where
appropriate, age, biological, and sociocultural contexts, in
all aspects of the Centers' work, including prevention
programs, public and professional education, services, and
treatment;
``(2) establish short-range and long-range goals and
objectives within the Centers for women's health and, as
relevant and appropriate, coordinate with other appropriate
offices on activities within the Centers that relate to
prevention, research, education and training, service
delivery, and policy development, for issues of particular
concern to women;
``(3) identify projects in women's health that should be
conducted or supported by the Centers;
``(4) consult with health professionals, nongovernmental
organizations, consumer organizations, women's health
professionals, and other individuals and groups, as
appropriate, on the policy of the Centers with regard to
women; and
``(5) serve as a member of the Department of Health and
Human Services Coordinating Committee on Women's Health
(established under section 229(b)(4)).
``(c) Definition.--As used in this section, the term
`women's health conditions', with respect to women of all
age, ethnic, and racial groups, means diseases, disorders,
and conditions--
``(1) unique to, significantly more serious for, or
significantly more prevalent in women; and
``(2) for which the factors of medical risk or type of
medical intervention are different for women, or for which
there is reasonable evidence that indicates that such factors
or types may be different for women.
``(d) Authorization of Appropriations.--For the purpose of
carrying out this section, there are authorized to be
appropriated such sums as may be necessary for each of the
fiscal years 2010 through 2014.''.
(c) Office of Women's Health Research.--Section 486(a) of
the Public Health Service Act (42 U.S.C. 287d(a)) is amended
by inserting ``and who shall report directly to the
Director'' before the period at the end thereof.
(d) Substance Abuse and Mental Health Services
Administration.--Section 501(f) of the Public Health Service
Act (42 U.S.C. 290aa(f)) is amended--
(1) in paragraph (1), by inserting ``who shall report
directly to the Administrator'' before the period;
(2) by redesignating paragraph (4) as paragraph (5); and
(3) by inserting after paragraph (3), the following:
``(4) Office.--Nothing in this subsection shall be
construed to preclude the Secretary from establishing within
the Substance Abuse and Mental Health Administration an
Office of Women's Health.''.
(e) Agency for Healthcare Research and Quality Activities
Regarding Women's Health.--Part C of title IX of the Public
Health Service Act (42 U.S.C. 299c et seq.) is amended--
(1) by redesignating sections 925 and 926 as sections 926
and 927, respectively; and
(2) by inserting after section 924 the following:
``SEC. 925. ACTIVITIES REGARDING WOMEN'S HEALTH.
``(a) Establishment.--There is established within the
Office of the Director, an Office of Women's Health and
Gender-Based Research (referred to in this section as the
`Office'). The Office shall be headed by a director who shall
be appointed by the Director of Healthcare and Research
Quality.
``(b) Purpose.--The official designated under subsection
(a) shall--
``(1) report to the Director on the current Agency level of
activity regarding women's health, across, where appropriate,
age, biological, and sociocultural contexts, in all aspects
of Agency work, including the development of evidence reports
and clinical practice protocols and the conduct of research
into patient outcomes, delivery of health care services,
quality of care, and access to health care;
``(2) establish short-range and long-range goals and
objectives within the Agency for research important to
women's health and, as relevant and appropriate, coordinate
with other appropriate offices on activities within the
Agency that relate to health services and medical
effectiveness research, for issues of particular concern to
women;
``(3) identify projects in women's health that should be
conducted or supported by the Agency;
``(4) consult with health professionals, nongovernmental
organizations, consumer organizations, women's health
professionals, and other individuals and groups, as
appropriate, on Agency policy with regard to women; and
``(5) serve as a member of the Department of Health and
Human Services Coordinating Committee on Women's Health
(established under section 229(b)(4)).''.
``(c) Authorization of Appropriations.--For the purpose of
carrying out this section, there are authorized to be
appropriated such sums as may be necessary for each of the
fiscal years 2010 through 2014.''.
(f) Health Resources and Services Administration Office of
Women's Health.--Title VII of the Social Security Act (42
U.S.C. 901 et seq.) is amended by adding at the end the
following:
[[Page H2028]]
``SEC. 713. OFFICE OF WOMEN'S HEALTH.
``(a) Establishment.--The Secretary shall establish within
the Office of the Administrator of the Health Resources and
Services Administration, an office to be known as the Office
of Women's Health. The Office shall be headed by a director
who shall be appointed by the Administrator.
``(b) Purpose.--The Director of the Office shall--
``(1) report to the Administrator on the current
Administration level of activity regarding women's health
across, where appropriate, age, biological, and sociocultural
contexts;
``(2) establish short-range and long-range goals and
objectives within the Health Resources and Services
Administration for women's health and, as relevant and
appropriate, coordinate with other appropriate offices on
activities within the Administration that relate to health
care provider training, health service delivery, research,
and demonstration projects, for issues of particular concern
to women;
``(3) identify projects in women's health that should be
conducted or supported by the bureaus of the Administration;
``(4) consult with health professionals, nongovernmental
organizations, consumer organizations, women's health
professionals, and other individuals and groups, as
appropriate, on Administration policy with regard to women;
and
``(5) serve as a member of the Department of Health and
Human Services Coordinating Committee on Women's Health
(established under section 229(b)(4) of the Public Health
Service Act).
``(c) Continued Administration of Existing Programs.--The
Director of the Office shall assume the authority for the
development, implementation, administration, and evaluation
of any projects carried out through the Health Resources and
Services Administration relating to women's health on the
date of enactment of this section.
``(d) Definitions.--For purposes of this section:
``(1) Administration.--The term `Administration' means the
Health Resources and Services Administration.
``(2) Administrator.--The term `Administrator' means the
Administrator of the Health Resources and Services
Administration.
``(3) Office.--The term `Office' means the Office of
Women's Health established under this section in the
Administration.
``(e) Authorization of Appropriations.--For the purpose of
carrying out this section, there are authorized to be
appropriated such sums as may be necessary for each of the
fiscal years 2010 through 2014.''.
(g) Food and Drug Administration Office of Women's
Health.--Chapter X of the Federal Food, Drug, and Cosmetic
Act (21 U.S.C. 391 et seq.) is amended by adding at the end
the following:
``SEC. 1011. OFFICE OF WOMEN'S HEALTH.
``(a) Establishment.--There is established within the
Office of the Commissioner, an office to be known as the
Office of Women's Health (referred to in this section as the
`Office'). The Office shall be headed by a director who shall
be appointed by the Commissioner of Food and Drugs.
``(b) Purpose.--The Director of the Office shall--
``(1) report to the Commissioner of Food and Drugs on
current Food and Drug Administration (referred to in this
section as the `Administration') levels of activity regarding
women's participation in clinical trials and the analysis of
data by sex in the testing of drugs, medical devices, and
biological products across, where appropriate, age,
biological, and sociocultural contexts;
``(2) establish short-range and long-range goals and
objectives within the Administration for issues of particular
concern to women's health within the jurisdiction of the
Administration, including, where relevant and appropriate,
adequate inclusion of women and analysis of data by sex in
Administration protocols and policies;
``(3) provide information to women and health care
providers on those areas in which differences between men and
women exist;
``(4) consult with pharmaceutical, biologics, and device
manufacturers, health professionals with expertise in women's
issues, consumer organizations, and women's health
professionals on Administration policy with regard to women;
``(5) make annual estimates of funds needed to monitor
clinical trials and analysis of data by sex in accordance
with needs that are identified; and
``(6) serve as a member of the Department of Health and
Human Services Coordinating Committee on Women's Health
(established under section 229(b)(4) of the Public Health
Service Act).
``(c) Authorization of Appropriations.--For the purpose of
carrying out this section, there are authorized to be
appropriated such sums as may be necessary for each of the
fiscal years 2010 through 2014.''.
(h) No New Regulatory Authority.--Nothing in this section
and the amendments made by this section may be construed as
establishing regulatory authority or modifying any existing
regulatory authority.
(i) Limitation on Termination.--Notwithstanding any other
provision of law, a Federal office of women's health
(including the Office of Research on Women's Health of the
National Institutes of Health) or Federal appointive position
with primary responsibility over women's health issues
(including the Associate Administrator for Women's Services
under the Substance Abuse and Mental Health Services
Administration) that is in existence on the date of enactment
of this section shall not be terminated, reorganized, or have
any of it's powers or duties transferred unless such
termination, reorganization, or transfer is approved by
Congress through the adoption of a concurrent resolution of
approval.
(j) Rule of Construction.--Nothing in this section (or the
amendments made by this section) shall be construed to limit
the authority of the Secretary of Health and Human Services
with respect to women's health, or with respect to activities
carried out through the Department of Health and Human
Services on the date of enactment of this section.
SEC. 3510. PATIENT NAVIGATOR PROGRAM.
Section 340A of the Public Health Service Act (42 U.S.C.
256a) is amended--
(1) by striking subsection (d)(3) and inserting the
following:
``(3) Limitations on grant period.--In carrying out this
section, the Secretary shall ensure that the total period of
a grant does not exceed 4 years.'';
(2) in subsection (e), by adding at the end the following:
``(3) Minimum core proficiencies.--The Secretary shall not
award a grant to an entity under this section unless such
entity provides assurances that patient navigators recruited,
assigned, trained, or employed using grant funds meet minimum
core proficiencies, as defined by the entity that submits the
application, that are tailored for the main focus or
intervention of the navigator involved.''; and
(3) in subsection (m)--
(A) in paragraph (1), by striking ``and $3,500,000 for
fiscal year 2010.'' and inserting ``$3,500,000 for fiscal
year 2010, and such sums as may be necessary for each of
fiscal years 2011 through 2015.''; and
(B) in paragraph (2), by striking ``2010'' and inserting
``2015''.
SEC. 3511. AUTHORIZATION OF APPROPRIATIONS.
Except where otherwise provided in this subtitle (or an
amendment made by this subtitle), there is authorized to be
appropriated such sums as may be necessary to carry out this
subtitle (and such amendments made by this subtitle).
Subtitle G--Protecting and Improving Guaranteed Medicare Benefits
SEC. 3601. PROTECTING AND IMPROVING GUARANTEED MEDICARE
BENEFITS.
(a) Protecting Guaranteed Medicare Benefits.--Nothing in
the provisions of, or amendments made by, this Act shall
result in a reduction of guaranteed benefits under title
XVIII of the Social Security Act.
(b) Ensuring That Medicare Savings Benefit the Medicare
Program and Medicare Beneficiaries.--Savings generated for
the Medicare program under title XVIII of the Social Security
Act under the provisions of, and amendments made by, this Act
shall extend the solvency of the Medicare trust funds, reduce
Medicare premiums and other cost-sharing for beneficiaries,
and improve or expand guaranteed Medicare benefits and
protect access to Medicare providers.
SEC. 3602. NO CUTS IN GUARANTEED BENEFITS.
Nothing in this Act shall result in the reduction or
elimination of any benefits guaranteed by law to participants
in Medicare Advantage plans.
TITLE IV--PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH
Subtitle A--Modernizing Disease Prevention and Public Health Systems
SEC. 4001. NATIONAL PREVENTION, HEALTH PROMOTION AND PUBLIC
HEALTH COUNCIL.
(a) Establishment.--The President shall establish, within
the Department of Health and Human Services, a council to be
known as the ``National Prevention, Health Promotion and
Public Health Council'' (referred to in this section as the
``Council'').
(b) Chairperson.--The President shall appoint the Surgeon
General to serve as the chairperson of the Council.
(c) Composition.--The Council shall be composed of--
(1) the Secretary of Health and Human Services;
(2) the Secretary of Agriculture;
(3) the Secretary of Education;
(4) the Chairman of the Federal Trade Commission;
(5) the Secretary of Transportation;
(6) the Secretary of Labor;
(7) the Secretary of Homeland Security;
(8) the Administrator of the Environmental Protection
Agency;
(9) the Director of the Office of National Drug Control
Policy;
(10) the Director of the Domestic Policy Council;
(11) the Assistant Secretary for Indian Affairs;
(12) the Chairman of the Corporation for National and
Community Service; and
(13) the head of any other Federal agency that the
chairperson determines is appropriate.
(d) Purposes and Duties.--The Council shall--
(1) provide coordination and leadership at the Federal
level, and among all Federal departments and agencies, with
respect to prevention, wellness and health promotion
practices, the public health system, and integrative health
care in the United States;
(2) after obtaining input from relevant stakeholders,
develop a national prevention, health promotion, public
health, and integrative health care strategy that
incorporates the most effective and achievable means of
improving the health status of Americans and reducing the
incidence of preventable illness and disability in the United
States;
(3) provide recommendations to the President and Congress
concerning the most pressing health issues confronting the
United States and changes in Federal policy to achieve
national
[[Page H2029]]
wellness, health promotion, and public health goals,
including the reduction of tobacco use, sedentary behavior,
and poor nutrition;
(4) consider and propose evidence-based models, policies,
and innovative approaches for the promotion of transformative
models of prevention, integrative health, and public health
on individual and community levels across the United States;
(5) establish processes for continual public input,
including input from State, regional, and local leadership
communities and other relevant stakeholders, including Indian
tribes and tribal organizations;
(6) submit the reports required under subsection (g); and
(7) carry out other activities determined appropriate by
the President.
(e) Meetings.--The Council shall meet at the call of the
Chairperson.
(f) Advisory Group.--
(1) In general.--The President shall establish an Advisory
Group to the Council to be known as the ``Advisory Group on
Prevention, Health Promotion, and Integrative and Public
Health'' (hereafter referred to in this section as the
``Advisory Group''). The Advisory Group shall be within the
Department of Health and Human Services and report to the
Surgeon General.
(2) Composition.--
(A) In general.--The Advisory Group shall be composed of
not more than 25 non-Federal members to be appointed by the
President.
(B) Representation.--In appointing members under
subparagraph (A), the President shall ensure that the
Advisory Group includes a diverse group of licensed health
professionals, including integrative health practitioners who
have expertise in--
(i) worksite health promotion;
(ii) community services, including community health
centers;
(iii) preventive medicine;
(iv) health coaching;
(v) public health education;
(vi) geriatrics; and
(vii) rehabilitation medicine.
(3) Purposes and duties.--The Advisory Group shall develop
policy and program recommendations and advise the Council on
lifestyle-based chronic disease prevention and management,
integrative health care practices, and health promotion.
(g) National Prevention and Health Promotion Strategy.--Not
later than 1 year after the date of enactment of this Act,
the Chairperson, in consultation with the Council, shall
develop and make public a national prevention, health
promotion and public health strategy, and shall review and
revise such strategy periodically. Such strategy shall--
(1) set specific goals and objectives for improving the
health of the United States through federally-supported
prevention, health promotion, and public health programs,
consistent with ongoing goal setting efforts conducted by
specific agencies;
(2) establish specific and measurable actions and timelines
to carry out the strategy, and determine accountability for
meeting those timelines, within and across Federal
departments and agencies; and
(3) make recommendations to improve Federal efforts
relating to prevention, health promotion, public health, and
integrative health care practices to ensure Federal efforts
are consistent with available standards and evidence.
(h) Report.--Not later than July 1, 2010, and annually
thereafter through January 1, 2015, the Council shall submit
to the President and the relevant committees of Congress, a
report that--
(1) describes the activities and efforts on prevention,
health promotion, and public health and activities to develop
a national strategy conducted by the Council during the
period for which the report is prepared;
(2) describes the national progress in meeting specific
prevention, health promotion, and public health goals defined
in the strategy and further describes corrective actions
recommended by the Council and taken by relevant agencies and
organizations to meet these goals;
(3) contains a list of national priorities on health
promotion and disease prevention to address lifestyle
behavior modification (smoking cessation, proper nutrition,
appropriate exercise, mental health, behavioral health,
substance use disorder, and domestic violence screenings) and
the prevention measures for the 5 leading disease killers in
the United States;
(4) contains specific science-based initiatives to achieve
the measurable goals of Healthy People 2010 regarding
nutrition, exercise, and smoking cessation, and targeting the
5 leading disease killers in the United States;
(5) contains specific plans for consolidating Federal
health programs and Centers that exist to promote healthy
behavior and reduce disease risk (including eliminating
programs and offices determined to be ineffective in meeting
the priority goals of Healthy People 2010);
(6) contains specific plans to ensure that all Federal
health care programs are fully coordinated with science-based
prevention recommendations by the Director of the Centers for
Disease Control and Prevention; and
(7) contains specific plans to ensure that all non-
Department of Health and Human Services prevention programs
are based on the science-based guidelines developed by the
Centers for Disease Control and Prevention under paragraph
(4).
(i) Periodic Reviews.--The Secretary and the Comptroller
General of the United States shall jointly conduct periodic
reviews, not less than every 5 years, and evaluations of
every Federal disease prevention and health promotion
initiative, program, and agency. Such reviews shall be
evaluated based on effectiveness in meeting metrics-based
goals with an analysis posted on such agencies' public
Internet websites.
SEC. 4002. PREVENTION AND PUBLIC HEALTH FUND.
(a) Purpose.--It is the purpose of this section to
establish a Prevention and Public Health Fund (referred to in
this section as the ``Fund''), to be administered through the
Department of Health and Human Services, Office of the
Secretary, to provide for expanded and sustained national
investment in prevention and public health programs to
improve health and help restrain the rate of growth in
private and public sector health care costs.
(b) Funding.--There are hereby authorized to be
appropriated, and appropriated, to the Fund, out of any
monies in the Treasury not otherwise appropriated--
(1) for fiscal year 2010, $500,000,000;
(2) for fiscal year 2011, $750,000,000;
(3) for fiscal year 2012, $1,000,000,000;
(4) for fiscal year 2013, $1,250,000,000;
(5) for fiscal year 2014, $1,500,000,000; and
(6) for fiscal year 2015, and each fiscal year thereafter,
$2,000,000,000.
(c) Use of Fund.--The Secretary shall transfer amounts in
the Fund to accounts within the Department of Health and
Human Services to increase funding, over the fiscal year 2008
level, for programs authorized by the Public Health Service
Act, for prevention, wellness, and public health activities
including prevention research and health screenings, such as
the Community Transformation grant program, the Education and
Outreach Campaign for Preventive Benefits, and immunization
programs.
(d) Transfer Authority.--The Committee on Appropriations of
the Senate and the Committee on Appropriations of the House
of Representatives may provide for the transfer of funds in
the Fund to eligible activities under this section, subject
to subsection (c).
SEC. 4003. CLINICAL AND COMMUNITY PREVENTIVE SERVICES.
(a) Preventive Services Task Force.--Section 915 of the
Public Health Service Act (42 U.S.C. 299b-4) is amended by
striking subsection (a) and inserting the following:
``(a) Preventive Services Task Force.--
``(1) Establishment and purpose.--The Director shall
convene an independent Preventive Services Task Force
(referred to in this subsection as the `Task Force') to be
composed of individuals with appropriate expertise. Such Task
Force shall review the scientific evidence related to the
effectiveness, appropriateness, and cost-effectiveness of
clinical preventive services for the purpose of developing
recommendations for the health care community, and updating
previous clinical preventive recommendations, to be published
in the Guide to Clinical Preventive Services (referred to in
this section as the `Guide'), for individuals and
organizations delivering clinical services, including primary
care professionals, health care systems, professional
societies, employers, community organizations, non-profit
organizations, Congress and other policy-makers, governmental
public health agencies, health care quality organizations,
and organizations developing national health objectives. Such
recommendations shall consider clinical preventive best
practice recommendations from the Agency for Healthcare
Research and Quality, the National Institutes of Health, the
Centers for Disease Control and Prevention, the Institute of
Medicine, specialty medical associations, patient groups, and
scientific societies.
``(2) Duties.--The duties of the Task Force shall include--
``(A) the development of additional topic areas for new
recommendations and interventions related to those topic
areas, including those related to specific sub-populations
and age groups;
``(B) at least once during every 5-year period, review
interventions and update recommendations related to existing
topic areas, including new or improved techniques to assess
the health effects of interventions;
``(C) improved integration with Federal Government health
objectives and related target setting for health improvement;
``(D) the enhanced dissemination of recommendations;
``(E) the provision of technical assistance to those health
care professionals, agencies and organizations that request
help in implementing the Guide recommendations; and
``(F) the submission of yearly reports to Congress and
related agencies identifying gaps in research, such as
preventive services that receive an insufficient evidence
statement, and recommending priority areas that deserve
further examination, including areas related to populations
and age groups not adequately addressed by current
recommendations.
``(3) Role of agency.--The Agency shall provide ongoing
administrative, research, and technical support for the
operations of the Task Force, including coordinating and
supporting the dissemination of the recommendations of the
Task Force, ensuring adequate staff resources, and assistance
to those organizations requesting it for implementation of
the Guide's recommendations.
``(4) Coordination with community preventive services task
force.--The Task Force shall take appropriate steps to
coordinate its work with the Community Preventive Services
Task Force and the Advisory Committee on Immunization
Practices, including the examination of how each task force's
recommendations interact at the nexus of clinic and
community.
``(5) Operation.--Operation. In carrying out the duties
under paragraph (2), the Task Force is not subject to the
provisions of Appendix 2 of title 5, United States Code.
``(6) Independence.--All members of the Task Force convened
under this subsection, and any recommendations made by such
members, shall be independent and, to the extent practicable,
not subject to political pressure.
``(7) Authorization of appropriations.--There are
authorized to be appropriated such
[[Page H2030]]
sums as may be necessary for each fiscal year to carry out
the activities of the Task Force.''.
(b) Community Preventive Services Task Force.--
(1) In general.--Part P of title III of the Public Health
Service Act, as amended by paragraph (2), is amended by
adding at the end the following:
``SEC. 399U. COMMUNITY PREVENTIVE SERVICES TASK FORCE.
``(a) Establishment and Purpose.--The Director of the
Centers for Disease Control and Prevention shall convene an
independent Community Preventive Services Task Force
(referred to in this subsection as the `Task Force') to be
composed of individuals with appropriate expertise. Such Task
Force shall review the scientific evidence related to the
effectiveness, appropriateness, and cost-effectiveness of
community preventive interventions for the purpose of
developing recommendations, to be published in the Guide to
Community Preventive Services (referred to in this section as
the `Guide'), for individuals and organizations delivering
population-based services, including primary care
professionals, health care systems, professional societies,
employers, community organizations, non-profit organizations,
schools, governmental public health agencies, Indian tribes,
tribal organizations and urban Indian organizations, medical
groups, Congress and other policy-makers. Community
preventive services include any policies, programs, processes
or activities designed to affect or otherwise affecting
health at the population level.
``(b) Duties.--The duties of the Task Force shall include--
``(1) the development of additional topic areas for new
recommendations and interventions related to those topic
areas, including those related to specific populations and
age groups, as well as the social, economic and physical
environments that can have broad effects on the health and
disease of populations and health disparities among sub-
populations and age groups;
``(2) at least once during every 5-year period, review
interventions and update recommendations related to existing
topic areas, including new or improved techniques to assess
the health effects of interventions, including health impact
assessment and population health modeling;
``(3) improved integration with Federal Government health
objectives and related target setting for health improvement;
``(4) the enhanced dissemination of recommendations;
``(5) the provision of technical assistance to those health
care professionals, agencies, and organizations that request
help in implementing the Guide recommendations; and
``(6) providing yearly reports to Congress and related
agencies identifying gaps in research and recommending
priority areas that deserve further examination, including
areas related to populations and age groups not adequately
addressed by current recommendations.
``(c) Role of Agency.--The Director shall provide ongoing
administrative, research, and technical support for the
operations of the Task Force, including coordinating and
supporting the dissemination of the recommendations of the
Task Force, ensuring adequate staff resources, and assistance
to those organizations requesting it for implementation of
Guide recommendations.
``(d) Coordination With Preventive Services Task Force.--
The Task Force shall take appropriate steps to coordinate its
work with the U.S. Preventive Services Task Force and the
Advisory Committee on Immunization Practices, including the
examination of how each task force's recommendations interact
at the nexus of clinic and community.
``(e) Operation.--In carrying out the duties under
subsection (b), the Task Force shall not be subject to the
provisions of Appendix 2 of title 5, United States Code.
``(f) Authorization of Appropriations.--There are
authorized to be appropriated such sums as may be necessary
for each fiscal year to carry out the activities of the Task
Force.''.
(2) Technical amendments.--
(A) Section 399R of the Public Health Service Act (as added
by section 2 of the ALS Registry Act (Public Law 110-373; 122
Stat. 4047)) is redesignated as section 399S.
(B) Section 399R of such Act (as added by section 3 of the
Prenatally and Postnatally Diagnosed Conditions Awareness Act
(Public Law 110-374; 122 Stat. 4051)) is redesignated as
section 399T.
SEC. 4004. EDUCATION AND OUTREACH CAMPAIGN REGARDING
PREVENTIVE BENEFITS.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary'') shall
provide for the planning and implementation of a national
public-private partnership for a prevention and health
promotion outreach and education campaign to raise public
awareness of health improvement across the life span. Such
campaign shall include the dissemination of information
that--
(1) describes the importance of utilizing preventive
services to promote wellness, reduce health disparities, and
mitigate chronic disease;
(2) promotes the use of preventive services recommended by
the United States Preventive Services Task Force and the
Community Preventive Services Task Force;
(3) encourages healthy behaviors linked to the prevention
of chronic diseases;
(4) explains the preventive services covered under health
plans offered through a Gateway;
(5) describes additional preventive care supported by the
Centers for Disease Control and Prevention, the Health
Resources and Services Administration, the Substance Abuse
and Mental Health Services Administration, the Advisory
Committee on Immunization Practices, and other appropriate
agencies; and
(6) includes general health promotion information.
(b) Consultation.--In coordinating the campaign under
subsection (a), the Secretary shall consult with the
Institute of Medicine to provide ongoing advice on evidence-
based scientific information for policy, program development,
and evaluation.
(c) Media Campaign.--
(1) In general.--Not later than 1 year after the date of
enactment of this Act, the Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall establish and implement a national science-based media
campaign on health promotion and disease prevention.
(2) Requirement of campaign.--The campaign implemented
under paragraph (1)--
(A) shall be designed to address proper nutrition, regular
exercise, smoking cessation, obesity reduction, the 5 leading
disease killers in the United States, and secondary
prevention through disease screening promotion;
(B) shall be carried out through competitively bid
contracts awarded to entities providing for the professional
production and design of such campaign;
(C) may include the use of television, radio, Internet, and
other commercial marketing venues and may be targeted to
specific age groups based on peer-reviewed social research;
(D) shall not be duplicative of any other Federal efforts
relating to health promotion and disease prevention; and
(E) may include the use of humor and nationally recognized
positive role models.
(3) Evaluation.--The Secretary shall ensure that the
campaign implemented under paragraph (1) is subject to an
independent evaluation every 2 years and shall report every 2
years to Congress on the effectiveness of such campaigns
towards meeting science-based metrics.
(d) Website.--The Secretary, in consultation with private-
sector experts, shall maintain or enter into a contract to
maintain an Internet website to provide science-based
information on guidelines for nutrition, regular exercise,
obesity reduction, smoking cessation, and specific chronic
disease prevention. Such website shall be designed to provide
information to health care providers and consumers.
(e) Dissemination of Information Through Providers.--The
Secretary, acting through the Centers for Disease Control and
Prevention, shall develop and implement a plan for the
dissemination of health promotion and disease prevention
information consistent with national priorities, to health
care providers who participate in Federal programs, including
programs administered by the Indian Health Service, the
Department of Veterans Affairs, the Department of Defense,
and the Health Resources and Services Administration, and
Medicare and Medicaid.
(f) Personalized Prevention Plans.--
(1) Contract.--The Secretary, acting through the Director
of the Centers for Disease Control and Prevention, shall
enter into a contract with a qualified entity for the
development and operation of a Federal Internet website
personalized prevention plan tool.
(2) Use.--The website developed under paragraph (1) shall
be designed to be used as a source of the most up-to-date
scientific evidence relating to disease prevention for use by
individuals. Such website shall contain a component that
enables an individual to determine their disease risk (based
on personal health and family history, BMI, and other
relevant information) relating to the 5 leading diseases in
the United States, and obtain personalized suggestions for
preventing such diseases.
(g) Internet Portal.--The Secretary shall establish an
Internet portal for accessing risk-assessment tools developed
and maintained by private and academic entities.
(h) Priority Funding.--Funding for the activities
authorized under this section shall take priority over
funding provided through the Centers for Disease Control and
Prevention for grants to States and other entities for
similar purposes and goals as provided for in this section.
Not to exceed $500,000,000 shall be expended on the campaigns
and activities required under this section.
(i) Public Awareness of Preventive and Obesity-Related
Services.--
(1) Information to states.--The Secretary of Health and
Human Services shall provide guidance and relevant
information to States and health care providers regarding
preventive and obesity-related services that are available to
Medicaid enrollees, including obesity screening and
counseling for children and adults.
(2) Information to enrollees.--Each State shall design a
public awareness campaign to educate Medicaid enrollees
regarding availability and coverage of such services, with
the goal of reducing incidences of obesity.
(3) Report.--Not later than January 1, 2011, and every 3
years thereafter through January 1, 2017, the Secretary of
Health and Human Services shall report to Congress on the
status and effectiveness of efforts under paragraphs (1) and
(2), including summaries of the States' efforts to increase
awareness of coverage of obesity-related services.
(j) Authorization of Appropriations.--There are authorized
to be appropriated such sums as may be necessary to carry out
this section.
Subtitle B--Increasing Access to Clinical Preventive Services
SEC. 4101. SCHOOL-BASED HEALTH CENTERS.
(a) Grants for the Establishment of School-Based Health
Centers.--
(1) Program.--The Secretary of Health and Human Services
(in this subsection referred to as the ``Secretary'') shall
establish a program to award grants to eligible entities to
support the operation of school-based health centers.
[[Page H2031]]
(2) Eligibility.--To be eligible for a grant under this
subsection, an entity shall--
(A) be a school-based health center or a sponsoring
facility of a school-based health center; and
(B) submit an application at such time, in such manner, and
containing such information as the Secretary may require,
including at a minimum an assurance that funds awarded under
the grant shall not be used to provide any service that is
not authorized or allowed by Federal, State, or local law.
(3) Preference.--In awarding grants under this section, the
Secretary shall give preference to awarding grants for
school-based health centers that serve a large population of
children eligible for medical assistance under the State
Medicaid plan under title XIX of the Social Security Act or
under a waiver of such plan or children eligible for child
health assistance under the State child health plan under
title XXI of that Act (42 U.S.C. 1397aa et seq.).
(4) Limitation on use of funds.--An eligible entity shall
use funds provided under a grant awarded under this
subsection only for expenditures for facilities (including
the acquisition or improvement of land, or the acquisition,
construction, expansion, replacement, or other improvement of
any building or other facility), equipment, or similar
expenditures, as specified by the Secretary. No funds
provided under a grant awarded under this section shall be
used for expenditures for personnel or to provide health
services.
(5) Appropriations.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated for each of
fiscal years 2010 through 2013, $50,000,000 for the purpose
of carrying out this subsection. Funds appropriated under
this paragraph shall remain available until expended.
(6) Definitions.--In this subsection, the terms ``school-
based health center'' and ``sponsoring facility'' have the
meanings given those terms in section 2110(c)(9) of the
Social Security Act (42 U.S.C. 1397jj(c)(9)).
(b) Grants for the Operation of School-Based Health
Centers.--Part Q of title III of the Public Health Service
Act (42 U.S.C. 280h et seq.) is amended by adding at the end
the following:
``SEC. 399Z-1. SCHOOL-BASED HEALTH CENTERS.
``(a) Definitions; Establishment of Criteria.--In this
section:
``(1) Comprehensive primary health services.--The term
`comprehensive primary health services' means the core
services offered by school-based health centers, which shall
include the following:
``(A) Physical.--Comprehensive health assessments,
diagnosis, and treatment of minor, acute, and chronic medical
conditions, and referrals to, and follow-up for, specialty
care and oral health services.
``(B) Mental health.--Mental health and substance use
disorder assessments, crisis intervention, counseling,
treatment, and referral to a continuum of services including
emergency psychiatric care, community support programs,
inpatient care, and outpatient programs.
``(2) Medically underserved children and adolescents.--
``(A) In general.--The term `medically underserved children
and adolescents' means a population of children and
adolescents who are residents of an area designated as a
medically underserved area or a health professional shortage
area by the Secretary.
``(B) Criteria.--The Secretary shall prescribe criteria for
determining the specific shortages of personal health
services for medically underserved children and adolescents
under subparagraph (A) that shall--
``(i) take into account any comments received by the
Secretary from the chief executive officer of a State and
local officials in a State; and
``(ii) include factors indicative of the health status of
such children and adolescents of an area, including the
ability of the residents of such area to pay for health
services, the accessibility of such services, the
availability of health professionals to such children and
adolescents, and other factors as determined appropriate by
the Secretary.
``(3) School-based health center.--The term `school-based
health center' means a health clinic that--
``(A) meets the definition of a school-based health center
under section 2110(c)(9)(A) of the Social Security Act and is
administered by a sponsoring facility (as defined in section
2110(c)(9)(B) of the Social Security Act);
``(B) provides, at a minimum, comprehensive primary health
services during school hours to children and adolescents by
health professionals in accordance with established
standards, community practice, reporting laws, and other
State laws, including parental consent and notification laws
that are not inconsistent with Federal law; and
``(C) does not perform abortion services.
``(b) Authority To Award Grants.--The Secretary shall award
grants for the costs of the operation of school-based health
centers (referred to in this section as `SBHCs') that meet
the requirements of this section.
``(c) Applications.--To be eligible to receive a grant
under this section, an entity shall--
``(1) be an SBHC (as defined in subsection (a)(3)); and
``(2) submit to the Secretary an application at such time,
in such manner, and containing--
``(A) evidence that the applicant meets all criteria
necessary to be designated an SBHC;
``(B) evidence of local need for the services to be
provided by the SBHC;
``(C) an assurance that--
``(i) SBHC services will be provided to those children and
adolescents for whom parental or guardian consent has been
obtained in cooperation with Federal, State, and local laws
governing health care service provision to children and
adolescents;
``(ii) the SBHC has made and will continue to make every
reasonable effort to establish and maintain collaborative
relationships with other health care providers in the
catchment area of the SBHC;
``(iii) the SBHC will provide on-site access during the
academic day when school is in session and 24-hour coverage
through an on-call system and through its backup health
providers to ensure access to services on a year-round basis
when the school or the SBHC is closed;
``(iv) the SBHC will be integrated into the school
environment and will coordinate health services with school
personnel, such as administrators, teachers, nurses,
counselors, and support personnel, as well as with other
community providers co-located at the school;
``(v) the SBHC sponsoring facility assumes all
responsibility for the SBHC administration, operations, and
oversight; and
``(vi) the SBHC will comply with Federal, State, and local
laws concerning patient privacy and student records,
including regulations promulgated under the Health Insurance
Portability and Accountability Act of 1996 and section 444 of
the General Education Provisions Act; and
``(D) such other information as the Secretary may require.
``(d) Preferences and Consideration.--In reviewing
applications:
``(1) The Secretary may give preference to applicants who
demonstrate an ability to serve the following:
``(A) Communities that have evidenced barriers to primary
health care and mental health and substance use disorder
prevention services for children and adolescents.
``(B) Communities with high per capita numbers of children
and adolescents who are uninsured, underinsured, or enrolled
in public health insurance programs.
``(C) Populations of children and adolescents that have
historically demonstrated difficulty in accessing health and
mental health and substance use disorder prevention services.
``(2) The Secretary may give consideration to whether an
applicant has received a grant under subsection (a) of
section 4101 of the Patient Protection and Affordable Care
Act.
``(e) Waiver of Requirements.--The Secretary may--
``(1) under appropriate circumstances, waive the
application of all or part of the requirements of this
subsection with respect to an SBHC for not to exceed 2 years;
and
``(2) upon a showing of good cause, waive the requirement
that the SBHC provide all required comprehensive primary
health services for a designated period of time to be
determined by the Secretary.
``(f) Use of Funds.--
``(1) Funds.--Funds awarded under a grant under this
section--
``(A) may be used for--
``(i) acquiring and leasing equipment (including the costs
of amortizing the principle of, and paying interest on, loans
for such equipment);
``(ii) providing training related to the provision of
required comprehensive primary health services and additional
health services;
``(iii) the management and operation of health center
programs;
``(iv) the payment of salaries for physicians, nurses, and
other personnel of the SBHC; and
``(B) may not be used to provide abortions.
``(2) Construction.--The Secretary may award grants which
may be used to pay the costs associated with expanding and
modernizing existing buildings for use as an SBHC, including
the purchase of trailers or manufactured buildings to install
on the school property.
``(3) Limitations.--
``(A) In general.--Any provider of services that is
determined by a State to be in violation of a State law
described in subsection (a)(3)(B) with respect to activities
carried out at a SBHC shall not be eligible to receive
additional funding under this section.
``(B) No overlapping grant period.--No entity that has
received funding under section 330 for a grant period shall
be eligible for a grant under this section for with respect
to the same grant period.
``(g) Matching Requirement.--
``(1) In general.--Each eligible entity that receives a
grant under this section shall provide, from non-Federal
sources, an amount equal to 20 percent of the amount of the
grant (which may be provided in cash or in-kind) to carry out
the activities supported by the grant.
``(2) Waiver.--The Secretary may waive all or part of the
matching requirement described in paragraph (1) for any
fiscal year for the SBHC if the Secretary determines that
applying the matching requirement to the SBHC would result in
serious hardship or an inability to carry out the purposes of
this section.
``(h) Supplement, Not Supplant.--Grant funds provided under
this section shall be used to supplement, not supplant, other
Federal or State funds.
``(i) Evaluation.--The Secretary shall develop and
implement a plan for evaluating SBHCs and monitoring quality
performance under the awards made under this section.
``(j) Age Appropriate Services.--An eligible entity
receiving funds under this section shall only provide age
appropriate services through a SBHC funded under this section
to an individual.
``(k) Parental Consent.--An eligible entity receiving funds
under this section shall not provide services through a SBHC
funded under this section to an individual without the
consent of the parent or guardian of such individual if such
individual is considered a minor under applicable State law.
``(l) Authorization of Appropriations.--For purposes of
carrying out this section, there are authorized to be
appropriated such sums as may be necessary for each of the
fiscal years 2010 through 2014.''.
[[Page H2032]]
SEC. 4102. ORAL HEALTHCARE PREVENTION ACTIVITIES.
(a) In General.--Title III of the Public Health Service Act
(42 U.S.C. 241 et seq.), as amended by section 3025, is
amended by adding at the end the following:
``PART T--ORAL HEALTHCARE PREVENTION ACTIVITIES
``SEC. 399LL. ORAL HEALTHCARE PREVENTION EDUCATION CAMPAIGN.
``(a) Establishment.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention
and in consultation with professional oral health
organizations, shall, subject to the availability of
appropriations, establish a 5-year national, public education
campaign (referred to in this section as the `campaign') that
is focused on oral healthcare prevention and education,
including prevention of oral disease such as early childhood
and other caries, periodontal disease, and oral cancer.
``(b) Requirements.--In establishing the campaign, the
Secretary shall--
``(1) ensure that activities are targeted towards specific
populations such as children, pregnant women, parents, the
elderly, individuals with disabilities, and ethnic and racial
minority populations, including Indians, Alaska Natives and
Native Hawaiians (as defined in section 4(c) of the Indian
Health Care Improvement Act) in a culturally and
linguistically appropriate manner; and
``(2) utilize science-based strategies to convey oral
health prevention messages that include, but are not limited
to, community water fluoridation and dental sealants.
``(c) Planning and Implementation.--Not later than 2 years
after the date of enactment of this section, the Secretary
shall begin implementing the 5-year campaign. During the 2-
year period referred to in the previous sentence, the
Secretary shall conduct planning activities with respect to
the campaign.
``SEC. 399LL-1. RESEARCH-BASED DENTAL CARIES DISEASE
MANAGEMENT.
``(a) In General.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall award demonstration grants to eligible entities to
demonstrate the effectiveness of research-based dental caries
disease management activities.
``(b) Eligibility.--To be eligible for a grant under this
section, an entity shall--
``(1) be a community-based provider of dental services (as
defined by the Secretary), including a Federally-qualified
health center, a clinic of a hospital owned or operated by a
State (or by an instrumentality or a unit of government
within a State), a State or local department of health, a
dental program of the Indian Health Service, an Indian tribe
or tribal organization, or an urban Indian organization (as
such terms are defined in section 4 of the Indian Health Care
Improvement Act), a health system provider, a private
provider of dental services, medical, dental, public health,
nursing, nutrition educational institutions, or national
organizations involved in improving children's oral health;
and
``(2) submit to the Secretary an application at such time,
in such manner, and containing such information as the
Secretary may require.
``(c) Use of Funds.--A grantee shall use amounts received
under a grant under this section to demonstrate the
effectiveness of research-based dental caries disease
management activities.
``(d) Use of Information.--The Secretary shall utilize
information generated from grantees under this section in
planning and implementing the public education campaign under
section 399LL.
``SEC. 399LL-2. AUTHORIZATION OF APPROPRIATIONS.
``There is authorized to be appropriated to carry out this
part, such sums as may be necessary.''.
(b) School-Based Sealant Programs.--Section 317M(c)(1) of
the Public Health Service Act (42 U.S.C. 247b-14(c)(1)) is
amended by striking ``may award grants to States and Indian
tribes'' and inserting ``shall award a grant to each of the
50 States and territories and to Indians, Indian tribes,
tribal organizations and urban Indian organizations (as such
terms are defined in section 4 of the Indian Health Care
Improvement Act)''.
(c) Oral Health Infrastructure.--Section 317M of the Public
Health Service Act (42 U.S.C. 247b-14) is amended--
(1) by redesignating subsections (d) and (e) as subsections
(e) and (f), respectively; and
(2) by inserting after subsection (c), the following:
``(d) Oral Health Infrastructure.--
``(1) Cooperative agreements.--The Secretary, acting
through the Director of the Centers for Disease Control and
Prevention, shall enter into cooperative agreements with
State, territorial, and Indian tribes or tribal organizations
(as those terms are defined in section 4 of the Indian Health
Care Improvement Act) to establish oral health leadership and
program guidance, oral health data collection and
interpretation, (including determinants of poor oral health
among vulnerable populations), a multi-dimensional delivery
system for oral health, and to implement science-based
programs (including dental sealants and community water
fluoridation) to improve oral health.
``(2) Authorization of appropriations.--There is authorized
to be appropriated such sums as necessary to carry out this
subsection for fiscal years 2010 through 2014.''.
(d) Updating National Oral Healthcare Surveillance
Activities.--
(1) PRAMS.--
(A) In general.--The Secretary of Health and Human Services
(referred to in this subsection as the ``Secretary'') shall
carry out activities to update and improve the Pregnancy Risk
Assessment Monitoring System (referred to in this section as
``PRAMS'') as it relates to oral healthcare.
(B) State reports and mandatory measurements.--
(i) In general.--Not later than 5 years after the date of
enactment of this Act, and every 5 years thereafter, a State
shall submit to the Secretary a report concerning activities
conducted within the State under PRAMS.
(ii) Measurements.--The oral healthcare measurements
developed by the Secretary for use under PRAMS shall be
mandatory with respect to States for purposes of the State
reports under clause (i).
(C) Funding.--There is authorized to be appropriated to
carry out this paragraph, such sums as may be necessary.
(2) National health and nutrition examination survey.--The
Secretary shall develop oral healthcare components that shall
include tooth-level surveillance for inclusion in the
National Health and Nutrition Examination Survey. Such
components shall be updated by the Secretary at least every 6
years. For purposes of this paragraph, the term ``tooth-level
surveillance'' means a clinical examination where an examiner
looks at each dental surface, on each tooth in the mouth and
as expanded by the Division of Oral Health of the Centers for
Disease Control and Prevention.
(3) Medical expenditures panel survey.--The Secretary shall
ensure that the Medical Expenditures Panel Survey by the
Agency for Healthcare Research and Quality includes the
verification of dental utilization, expenditure, and coverage
findings through conduct of a look-back analysis.
(4) National oral health surveillance system.--
(A) Appropriations.--There is authorized to be
appropriated, such sums as may be necessary for each of
fiscal years 2010 through 2014 to increase the participation
of States in the National Oral Health Surveillance System
from 16 States to all 50 States, territories, and District of
Columbia.
(B) Requirements.--The Secretary shall ensure that the
National Oral Health Surveillance System include the
measurement of early childhood caries.
SEC. 4103. MEDICARE COVERAGE OF ANNUAL WELLNESS VISIT
PROVIDING A PERSONALIZED PREVENTION PLAN.
(a) Coverage of Personalized Prevention Plan Services.--
(1) In general.--Section 1861(s)(2) of the Social Security
Act (42 U.S.C. 1395x(s)(2)) is amended--
(A) in subparagraph (DD), by striking ``and'' at the end;
(B) in subparagraph (EE), by adding ``and'' at the end; and
(C) by adding at the end the following new subparagraph:
``(FF) personalized prevention plan services (as defined in
subsection (hhh));''.
(2) Conforming amendments.--Clauses (i) and (ii) of section
1861(s)(2)(K) of the Social Security Act (42 U.S.C.
1395x(s)(2)(K)) are each amended by striking ``subsection
(ww)(1)'' and inserting ``subsections (ww)(1) and (hhh)''.
(b) Personalized Prevention Plan Services Defined.--Section
1861 of the Social Security Act (42 U.S.C. 1395x) is amended
by adding at the end the following new subsection:
``Annual Wellness Visit
``(hhh)(1) The term `personalized prevention plan services'
means the creation of a plan for an individual--
``(A) that includes a health risk assessment (that meets
the guidelines established by the Secretary under paragraph
(4)(A)) of the individual that is completed prior to or as
part of the same visit with a health professional described
in paragraph (3); and
``(B) that--
``(i) takes into account the results of the health risk
assessment; and
``(ii) may contain the elements described in paragraph (2).
``(2) Subject to paragraph (4)(H), the elements described
in this paragraph are the following:
``(A) The establishment of, or an update to, the
individual's medical and family history.
``(B) A list of current providers and suppliers that are
regularly involved in providing medical care to the
individual (including a list of all prescribed medications).
``(C) A measurement of height, weight, body mass index (or
waist circumference, if appropriate), blood pressure, and
other routine measurements.
``(D) Detection of any cognitive impairment.
``(E) The establishment of, or an update to, the following:
``(i) A screening schedule for the next 5 to 10 years, as
appropriate, based on recommendations of the United States
Preventive Services Task Force and the Advisory Committee on
Immunization Practices, and the individual's health status,
screening history, and age-appropriate preventive services
covered under this title.
``(ii) A list of risk factors and conditions for which
primary, secondary, or tertiary prevention interventions are
recommended or are underway, including any mental health
conditions or any such risk factors or conditions that have
been identified through an initial preventive physical
examination (as described under subsection (ww)(1)), and a
list of treatment options and their associated risks and
benefits.
``(F) The furnishing of personalized health advice and a
referral, as appropriate, to health education or preventive
counseling services or programs aimed at reducing identified
risk factors and improving self-management, or community-
based lifestyle interventions to reduce health risks and
promote self-management and wellness, including weight loss,
physical activity, smoking cessation, fall prevention, and
nutrition.
[[Page H2033]]
``(G) Any other element determined appropriate by the
Secretary.
``(3) A health professional described in this paragraph
is--
``(A) a physician;
``(B) a practitioner described in clause (i) of section
1842(b)(18)(C); or
``(C) a medical professional (including a health educator,
registered dietitian, or nutrition professional) or a team of
medical professionals, as determined appropriate by the
Secretary, under the supervision of a physician.
``(4)(A) For purposes of paragraph (1)(A), the Secretary,
not later than 1 year after the date of enactment of this
subsection, shall establish publicly available guidelines for
health risk assessments. Such guidelines shall be developed
in consultation with relevant groups and entities and shall
provide that a health risk assessment--
``(i) identify chronic diseases, injury risks, modifiable
risk factors, and urgent health needs of the individual; and
``(ii) may be furnished--
``(I) through an interactive telephonic or web-based
program that meets the standards established under
subparagraph (B);
``(II) during an encounter with a health care professional;
``(III) through community-based prevention programs; or
``(IV) through any other means the Secretary determines
appropriate to maximize accessibility and ease of use by
beneficiaries, while ensuring the privacy of such
beneficiaries.
``(B) Not later than 1 year after the date of enactment of
this subsection, the Secretary shall establish standards for
interactive telephonic or web-based programs used to furnish
health risk assessments under subparagraph (A)(ii)(I). The
Secretary may utilize any health risk assessment developed
under section 4004(f) of the Patient Protection and
Affordable Care Act as part of the requirement to develop a
personalized prevention plan to comply with this
subparagraph.
``(C)(i) Not later than 18 months after the date of
enactment of this subsection, the Secretary shall develop and
make available to the public a health risk assessment model.
Such model shall meet the guidelines under subparagraph (A)
and may be used to meet the requirement under paragraph
(1)(A).
``(ii) Any health risk assessment that meets the guidelines
under subparagraph (A) and is approved by the Secretary may
be used to meet the requirement under paragraph (1)(A).
``(D) The Secretary may coordinate with community-based
entities (including State Health Insurance Programs, Area
Agencies on Aging, Aging and Disability Resource Centers, and
the Administration on Aging) to--
``(i) ensure that health risk assessments are accessible to
beneficiaries; and
``(ii) provide appropriate support for the completion of
health risk assessments by beneficiaries.
``(E) The Secretary shall establish procedures to make
beneficiaries and providers aware of the requirement that a
beneficiary complete a health risk assessment prior to or at
the same time as receiving personalized prevention plan
services.
``(F) To the extent practicable, the Secretary shall
encourage the use of, integration with, and coordination of
health information technology (including use of technology
that is compatible with electronic medical records and
personal health records) and may experiment with the use of
personalized technology to aid in the development of self-
management skills and management of and adherence to provider
recommendations in order to improve the health status of
beneficiaries.
``(G)(i) A beneficiary shall only be eligible to receive an
initial preventive physical examination (as defined under
subsection (ww)(1)) at any time during the 12-month period
after the date that the beneficiary's coverage begins under
part B and shall be eligible to receive personalized
prevention plan services under this subsection provided that
the beneficiary has not received such services within the
preceding 12-month period.
``(ii) The Secretary shall establish procedures to make
beneficiaries aware of the option to select an initial
preventive physical examination or personalized prevention
plan services during the period of 12 months after the date
that a beneficiary's coverage begins under part B, which
shall include information regarding any relevant differences
between such services.
``(H) The Secretary shall issue guidance that--
``(i) identifies elements under paragraph (2) that are
required to be provided to a beneficiary as part of their
first visit for personalized prevention plan services; and
``(ii) establishes a yearly schedule for appropriate
provision of such elements thereafter.''.
(c) Payment and Elimination of Cost-Sharing.--
(1) Payment and elimination of coinsurance.--Section
1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1))
is amended--
(A) in subparagraph (N), by inserting ``other than
personalized prevention plan services (as defined in section
1861(hhh)(1))'' after ``(as defined in section 1848(j)(3))'';
(B) by striking ``and'' before ``(W)''; and
(C) by inserting before the semicolon at the end the
following: ``, and (X) with respect to personalized
prevention plan services (as defined in section
1861(hhh)(1)), the amount paid shall be 100 percent of the
lesser of the actual charge for the services or the amount
determined under the payment basis determined under section
1848''.
(2) Payment under physician fee schedule.--Section
1848(j)(3) of the Social Security Act (42 U.S.C. 1395w-
4(j)(3)) is amended by inserting ``(2)(FF) (including
administration of the health risk assessment) ,'' after
``(2)(EE),''.
(3) Elimination of coinsurance in outpatient hospital
settings.--
(A) Exclusion from opd fee schedule.--Section
1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C.
1395l(t)(1)(B)(iv)) is amended by striking ``and diagnostic
mammography'' and inserting ``, diagnostic mammography, or
personalized prevention plan services (as defined in section
1861(hhh)(1))''.
(B) Conforming amendments.--Section 1833(a)(2) of the
Social Security Act (42 U.S.C. 1395l(a)(2)) is amended--
(i) in subparagraph (F), by striking ``and'' at the end;
(ii) in subparagraph (G)(ii), by striking the comma at the
end and inserting ``; and''; and
(iii) by inserting after subparagraph (G)(ii) the following
new subparagraph:
``(H) with respect to personalized prevention plan services
(as defined in section 1861(hhh)(1)) furnished by an
outpatient department of a hospital, the amount determined
under paragraph (1)(X),''.
(4) Waiver of application of deductible.--The first
sentence of section 1833(b) of the Social Security Act (42
U.S.C. 1395l(b)) is amended--
(A) by striking ``and'' before ``(9)''; and
(B) by inserting before the period the following: ``, and
(10) such deductible shall not apply with respect to
personalized prevention plan services (as defined in section
1861(hhh)(1))''.
(d) Frequency Limitation.--Section 1862(a) of the Social
Security Act (42 U.S.C. 1395y(a)) is amended--
(1) in paragraph (1)--
(A) in subparagraph (N), by striking ``and'' at the end;
(B) in subparagraph (O), by striking the semicolon at the
end and inserting ``, and''; and
(C) by adding at the end the following new subparagraph:
``(P) in the case of personalized prevention plan services
(as defined in section 1861(hhh)(1)), which are performed
more frequently than is covered under such section;''; and
(2) in paragraph (7), by striking ``or (K)'' and inserting
``(K), or (P)''.
(e) Effective Date.--The amendments made by this section
shall apply to services furnished on or after January 1,
2011.
SEC. 4104. REMOVAL OF BARRIERS TO PREVENTIVE SERVICES IN
MEDICARE.
(a) Definition of Preventive Services.--Section 1861(ddd)
of the Social Security Act (42 U.S.C. 1395x(ddd)) is
amended--
(1) in the heading, by inserting ``; Preventive Services''
after ``Services'';
(2) in paragraph (1), by striking ``not otherwise described
in this title'' and inserting ``not described in subparagraph
(A) or (C) of paragraph (3)''; and
(3) by adding at the end the following new paragraph:
``(3) The term `preventive services' means the following:
``(A) The screening and preventive services described in
subsection (ww)(2) (other than the service described in
subparagraph (M) of such subsection).
``(B) An initial preventive physical examination (as
defined in subsection (ww)).
``(C) Personalized prevention plan services (as defined in
subsection (hhh)(1)).''.
(b) Coinsurance.--
(1) General application.--
(A) In general.--Section 1833(a)(1) of the Social Security
Act (42 U.S.C. 1395l(a)(1)), as amended by section
4103(c)(1), is amended--
(i) in subparagraph (T), by inserting ``(or 100 percent if
such services are recommended with a grade of A or B by the
United States Preventive Services Task Force for any
indication or population and are appropriate for the
individual)'' after ``80 percent'';
(ii) in subparagraph (W)--
(I) in clause (i), by inserting ``(if such subparagraph
were applied, by substituting `100 percent' for `80
percent')'' after ``subparagraph (D)''; and
(II) in clause (ii), by striking ``80 percent'' and
inserting ``100 percent'';
(iii) by striking ``and'' before ``(X)''; and
(iv) by inserting before the semicolon at the end the
following: ``, and (Y) with respect to preventive services
described in subparagraphs (A) and (B) of section
1861(ddd)(3) that are appropriate for the individual and, in
the case of such services described in subparagraph (A), are
recommended with a grade of A or B by the United States
Preventive Services Task Force for any indication or
population, the amount paid shall be 100 percent of the
lesser of the actual charge for the services or the amount
determined under the fee schedule that applies to such
services under this part''.
(2) Elimination of coinsurance in outpatient hospital
settings.--
(A) Exclusion from opd fee schedule.--Section
1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C.
1395l(t)(1)(B)(iv)), as amended by section 4103(c)(3)(A), is
amended--
(i) by striking ``or'' before ``personalized prevention
plan services''; and
(ii) by inserting before the period the following: ``, or
preventive services described in subparagraphs (A) and (B) of
section 1861(ddd)(3) that are appropriate for the individual
and, in the case of such services described in subparagraph
(A), are recommended with a grade of A or B by the United
States Preventive Services Task Force for any indication or
population''.
(B) Conforming amendments.--Section 1833(a)(2) of the
Social Security Act (42 U.S.C. 1395l(a)(2)), as amended by
section 4103(c)(3)(B), is amended--
(i) in subparagraph (G)(ii), by striking ``and'' after the
semicolon at the end;
(ii) in subparagraph (H), by striking the comma at the end
and inserting ``; and''; and
[[Page H2034]]
(iii) by inserting after subparagraph (H) the following new
subparagraph:
``(I) with respect to preventive services described in
subparagraphs (A) and (B) of section 1861(ddd)(3) that are
appropriate for the individual and are furnished by an
outpatient department of a hospital and, in the case of such
services described in subparagraph (A), are recommended with
a grade of A or B by the United States Preventive Services
Task Force for any indication or population, the amount
determined under paragraph (1)(W) or (1)(Y),''.
(c) Waiver of Application of Deductible for Preventive
Services and Colorectal Cancer Screening Tests.--Section
1833(b) of the Social Security Act (42 U.S.C. 1395l(b)), as
amended by section 4103(c)(4), is amended--
(1) in paragraph (1), by striking ``items and services
described in section 1861(s)(10)(A)'' and inserting
``preventive services described in subparagraph (A) of
section 1861(ddd)(3) that are recommended with a grade of A
or B by the United States Preventive Services Task Force for
any indication or population and are appropriate for the
individual.''; and
(2) by adding at the end the following new sentence:
``Paragraph (1) of the first sentence of this subsection
shall apply with respect to a colorectal cancer screening
test regardless of the code that is billed for the
establishment of a diagnosis as a result of the test, or for
the removal of tissue or other matter or other procedure that
is furnished in connection with, as a result of, and in the
same clinical encounter as the screening test.''.
(d) Effective Date.--The amendments made by this section
shall apply to items and services furnished on or after
January 1, 2011.
SEC. 4105. EVIDENCE-BASED COVERAGE OF PREVENTIVE SERVICES IN
MEDICARE.
(a) Authority To Modify or Eliminate Coverage of Certain
Preventive Services.--Section 1834 of the Social Security Act
(42 U.S.C. 1395m) is amended by adding at the end the
following new subsection:
``(n) Authority To Modify or Eliminate Coverage of Certain
Preventive Services.--Notwithstanding any other provision of
this title, effective beginning on January 1, 2010, if the
Secretary determines appropriate, the Secretary may--
``(1) modify--
``(A) the coverage of any preventive service described in
subparagraph (A) of section 1861(ddd)(3) to the extent that
such modification is consistent with the recommendations of
the United States Preventive Services Task Force; and
``(B) the services included in the initial preventive
physical examination described in subparagraph (B) of such
section; and
``(2) provide that no payment shall be made under this
title for a preventive service described in subparagraph (A)
of such section that has not received a grade of A, B, C, or
I by such Task Force.''.
(b) Construction.--Nothing in the amendment made by
paragraph (1) shall be construed to affect the coverage of
diagnostic or treatment services under title XVIII of the
Social Security Act.
SEC. 4106. IMPROVING ACCESS TO PREVENTIVE SERVICES FOR
ELIGIBLE ADULTS IN MEDICAID.
(a) Clarification of Inclusion of Services.--Section
1905(a)(13) of the Social Security Act (42 U.S.C.
1396d(a)(13)) is amended to read as follows:
``(13) other diagnostic, screening, preventive, and
rehabilitative services, including--
``(A) any clinical preventive services that are assigned a
grade of A or B by the United States Preventive Services Task
Force;
``(B) with respect to an adult individual, approved
vaccines recommended by the Advisory Committee on
Immunization Practices (an advisory committee established by
the Secretary, acting through the Director of the Centers for
Disease Control and Prevention) and their administration; and
``(C) any medical or remedial services (provided in a
facility, a home, or other setting) recommended by a
physician or other licensed practitioner of the healing arts
within the scope of their practice under State law, for the
maximum reduction of physical or mental disability and
restoration of an individual to the best possible functional
level;''.
(b) Increased Fmap.--Section 1905(b) of the Social Security
Act (42 U.S.C. 1396d(b)), as amended by sections
2001(a)(3)(A) and 2004(c)(1), is amended in the first
sentence--
(1) by striking ``, and (4)'' and inserting ``, (4)''; and
(2) by inserting before the period the following: ``, and
(5) in the case of a State that provides medical assistance
for services and vaccines described in subparagraphs (A) and
(B) of subsection (a)(13), and prohibits cost-sharing for
such services and vaccines, the Federal medical assistance
percentage, as determined under this subsection and
subsection (y) (without regard to paragraph (1)(C) of such
subsection), shall be increased by 1 percentage point with
respect to medical assistance for such services and vaccines
and for items and services described in subsection
(a)(4)(D)''.
(c) Effective Date.--The amendments made under this section
shall take effect on January 1, 2013.
SEC. 4107. COVERAGE OF COMPREHENSIVE TOBACCO CESSATION
SERVICES FOR PREGNANT WOMEN IN MEDICAID.
(a) Requiring Coverage of Counseling and Pharmacotherapy
for Cessation of Tobacco Use by Pregnant Women.--Section 1905
of the Social Security Act (42 U.S.C. 1396d), as amended by
sections 2001(a)(3)(B) and 2303, is further amended--
(1) in subsection (a)(4)--
(A) by striking ``and'' before ``(C)''; and
(B) by inserting before the semicolon at the end the
following new subparagraph: ``; and (D) counseling and
pharmacotherapy for cessation of tobacco use by pregnant
women (as defined in subsection (bb))''; and
(2) by adding at the end the following:
``(bb)(1) For purposes of this title, the term `counseling
and pharmacotherapy for cessation of tobacco use by pregnant
women' means diagnostic, therapy, and counseling services and
pharmacotherapy (including the coverage of prescription and
nonprescription tobacco cessation agents approved by the Food
and Drug Administration) for cessation of tobacco use by
pregnant women who use tobacco products or who are being
treated for tobacco use that is furnished--
``(A) by or under the supervision of a physician; or
``(B) by any other health care professional who--
``(i) is legally authorized to furnish such services under
State law (or the State regulatory mechanism provided by
State law) of the State in which the services are furnished;
and
``(ii) is authorized to receive payment for other services
under this title or is designated by the Secretary for this
purpose.
``(2) Subject to paragraph (3), such term is limited to--
``(A) services recommended with respect to pregnant women
in `Treating Tobacco Use and Dependence: 2008 Update: A
Clinical Practice Guideline', published by the Public Health
Service in May 2008, or any subsequent modification of such
Guideline; and
``(B) such other services that the Secretary recognizes to
be effective for cessation of tobacco use by pregnant women.
``(3) Such term shall not include coverage for drugs or
biologicals that are not otherwise covered under this
title.''.
(b) Exception From Optional Restriction Under Medicaid
Prescription Drug Coverage.--Section 1927(d)(2)(F) of the
Social Security Act (42 U.S.C. 1396r-8(d)(2)(F)), as
redesignated by section 2502(a), is amended by inserting
before the period at the end the following: ``, except, in
the case of pregnant women when recommended in accordance
with the Guideline referred to in section 1905(bb)(2)(A),
agents approved by the Food and Drug Administration under the
over-the-counter monograph process for purposes of promoting,
and when used to promote, tobacco cessation''.
(c) Removal of Cost-Sharing for Counseling and
Pharmacotherapy for Cessation of Tobacco Use by Pregnant
Women.--
(1) General cost-sharing limitations.--Section 1916 of the
Social Security Act (42 U.S.C. 1396o) is amended in each of
subsections (a)(2)(B) and (b)(2)(B) by inserting ``, and
counseling and pharmacotherapy for cessation of tobacco use
by pregnant women (as defined in section 1905(bb)) and
covered outpatient drugs (as defined in subsection (k)(2) of
section 1927 and including nonprescription drugs described in
subsection (d)(2) of such section) that are prescribed for
purposes of promoting, and when used to promote, tobacco
cessation by pregnant women in accordance with the Guideline
referred to in section 1905(bb)(2)(A)'' after ``complicate
the pregnancy''.
(2) Application to alternative cost-sharing.--Section
1916A(b)(3)(B)(iii) of such Act (42 U.S.C. 1396o-
1(b)(3)(B)(iii)) is amended by inserting ``, and counseling
and pharmacotherapy for cessation of tobacco use by pregnant
women (as defined in section 1905(bb))'' after ``complicate
the pregnancy''.
(d) Effective Date.--The amendments made by this section
shall take effect on October 1, 2010.
SEC. 4108. INCENTIVES FOR PREVENTION OF CHRONIC DISEASES IN
MEDICAID.
(a) Initiatives.--
(1) Establishment.--
(A) In general.--The Secretary shall award grants to States
to carry out initiatives to provide incentives to Medicaid
beneficiaries who--
(i) successfully participate in a program described in
paragraph (3); and
(ii) upon completion of such participation, demonstrate
changes in health risk and outcomes, including the adoption
and maintenance of healthy behaviors by meeting specific
targets (as described in subsection (c)(2)).
(B) Purpose.--The purpose of the initiatives under this
section is to test approaches that may encourage behavior
modification and determine scalable solutions.
(2) Duration.--
(A) Initiation of program; resources.--The Secretary shall
awards grants to States beginning on January 1, 2011, or
beginning on the date on which the Secretary develops program
criteria, whichever is earlier. The Secretary shall develop
program criteria for initiatives under this section using
relevant evidence-based research and resources, including the
Guide to Community Preventive Services, the Guide to Clinical
Preventive Services, and the National Registry of Evidence-
Based Programs and Practices.
(B) Duration of program.--A State awarded a grant to carry
out initiatives under this section shall carry out such
initiatives within the 5-year period beginning on January 1,
2011, or beginning on the date on which the Secretary
develops program criteria, whichever is earlier. Initiatives
under this section shall be carried out by a State for a
period of not less than 3 years.
(3) Program described.--
(A) In general.--A program described in this paragraph is a
comprehensive, evidence-based, widely available, and easily
accessible program, proposed by the State and approved by the
Secretary, that is designed and uniquely suited to address
the needs of Medicaid beneficiaries and has demonstrated
success in helping individuals achieve one or more of the
following:
(i) Ceasing use of tobacco products.
[[Page H2035]]
(ii) Controlling or reducing their weight.
(iii) Lowering their cholesterol.
(iv) Lowering their blood pressure.
(v) Avoiding the onset of diabetes or, in the case of a
diabetic, improving the management of that condition.
(B) Co-morbidities.--A program under this section may also
address co-morbidities (including depression) that are
related to any of the conditions described in subparagraph
(A).
(C) Waiver authority.--The Secretary may waive the
requirements of section 1902(a)(1) (relating to
statewideness) of the Social Security Act for a State awarded
a grant to conduct an initiative under this section and shall
ensure that a State makes any program described in
subparagraph (A) available and accessible to Medicaid
beneficiaries.
(D) Flexibility in implementation.--A State may enter into
arrangements with providers participating in Medicaid,
community-based organizations, faith-based organizations,
public-private partnerships, Indian tribes, or similar
entities or organizations to carry out programs described in
subparagraph (A).
(4) Application.--Following the development of program
criteria by the Secretary, a State may submit an application,
in such manner and containing such information as the
Secretary may require, that shall include a proposal for
programs described in paragraph (3)(A) and a plan to make
Medicaid beneficiaries and providers participating in
Medicaid who reside in the State aware and informed about
such programs.
(b) Education and Outreach Campaign.--
(1) State awareness.--The Secretary shall conduct an
outreach and education campaign to make States aware of the
grants under this section.
(2) Provider and beneficiary education.--A State awarded a
grant to conduct an initiative under this section shall
conduct an outreach and education campaign to make Medicaid
beneficiaries and providers participating in Medicaid who
reside in the State aware of the programs described in
subsection (a)(3) that are to be carried out by the State
under the grant.
(c) Impact.--A State awarded a grant to conduct an
initiative under this section shall develop and implement a
system to--
(1) track Medicaid beneficiary participation in the program
and validate changes in health risk and outcomes with
clinical data, including the adoption and maintenance of
health behaviors by such beneficiaries;
(2) to the extent practicable, establish standards and
health status targets for Medicaid beneficiaries
participating in the program and measure the degree to which
such standards and targets are met;
(3) evaluate the effectiveness of the program and provide
the Secretary with such evaluations;
(4) report to the Secretary on processes that have been
developed and lessons learned from the program; and
(5) report on preventive services as part of reporting on
quality measures for Medicaid managed care programs.
(d) Evaluations and Reports.--
(1) Independent assessment.--The Secretary shall enter into
a contract with an independent entity or organization to
conduct an evaluation and assessment of the initiatives
carried out by States under this section, for the purpose of
determining--
(A) the effect of such initiatives on the use of health
care services by Medicaid beneficiaries participating in the
program;
(B) the extent to which special populations (including
adults with disabilities, adults with chronic illnesses, and
children with special health care needs) are able to
participate in the program;
(C) the level of satisfaction of Medicaid beneficiaries
with respect to the accessibility and quality of health care
services provided through the program; and
(D) the administrative costs incurred by State agencies
that are responsible for administration of the program.
(2) State reporting.--A State awarded a grant to carry out
initiatives under this section shall submit reports to the
Secretary, on a semi-annual basis, regarding the programs
that are supported by the grant funds. Such report shall
include information, as specified by the Secretary,
regarding--
(A) the specific uses of the grant funds;
(B) an assessment of program implementation and lessons
learned from the programs;
(C) an assessment of quality improvements and clinical
outcomes under such programs; and
(D) estimates of cost savings resulting from such programs.
(3) Initial report.--Not later than January 1, 2014, the
Secretary shall submit to Congress an initial report on such
initiatives based on information provided by States through
reports required under paragraph (2). The initial report
shall include an interim evaluation of the effectiveness of
the initiatives carried out with grants awarded under this
section and a recommendation regarding whether funding for
expanding or extending the initiatives should be extended
beyond January 1, 2016.
(4) Final report.--Not later than July 1, 2016, the
Secretary shall submit to Congress a final report on the
program that includes the results of the independent
assessment required under paragraph (1), together with
recommendations for such legislation and administrative
action as the Secretary determines appropriate.
(e) No Effect on Eligibility for, or Amount of, Medicaid or
Other Benefits.--Any incentives provided to a Medicaid
beneficiary participating in a program described in
subsection (a)(3) shall not be taken into account for
purposes of determining the beneficiary's eligibility for, or
amount of, benefits under the Medicaid program or any program
funded in whole or in part with Federal funds.
(f) Funding.--Out of any funds in the Treasury not
otherwise appropriated, there are appropriated for the 5-year
period beginning on January 1, 2011, $100,000,000 to the
Secretary to carry out this section. Amounts appropriated
under this subsection shall remain available until expended.
(g) Definitions.--In this section:
(1) Medicaid beneficiary.--The term ``Medicaid
beneficiary'' means an individual who is eligible for medical
assistance under a State plan or waiver under title XIX of
the Social Security Act (42 U.S.C. 1396 et seq.) and is
enrolled in such plan or waiver.
(2) State.--The term ``State'' has the meaning given that
term for purposes of title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).
Subtitle C--Creating Healthier Communities
SEC. 4201. COMMUNITY TRANSFORMATION GRANTS.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary''), acting
through the Director of the Centers for Disease Control and
Prevention (referred to in this section as the ``Director''),
shall award competitive grants to State and local
governmental agencies and community-based organizations for
the implementation, evaluation, and dissemination of
evidence-based community preventive health activities in
order to reduce chronic disease rates, prevent the
development of secondary conditions, address health
disparities, and develop a stronger evidence-base of
effective prevention programming.
(b) Eligibility.--To be eligible to receive a grant under
subsection (a), an entity shall--
(1) be--
(A) a State governmental agency;
(B) a local governmental agency;
(C) a national network of community-based organizations;
(D) a State or local non-profit organization; or
(E) an Indian tribe; and
(2) submit to the Director an application at such time, in
such a manner, and containing such information as the
Director may require, including a description of the program
to be carried out under the grant; and
(3) demonstrate a history or capacity, if funded, to
develop relationships necessary to engage key stakeholders
from multiple sectors within and beyond health care and
across a community, such as healthy futures corps and health
care providers.
(c) Use of Funds.--
(1) In general.--An eligible entity shall use amounts
received under a grant under this section to carry out
programs described in this subsection.
(2) Community transformation plan.--
(A) In general.--An eligible entity that receives a grant
under this section shall submit to the Director (for
approval) a detailed plan that includes the policy,
environmental, programmatic, and as appropriate
infrastructure changes needed to promote healthy living and
reduce disparities.
(B) Activities.--Activities within the plan may focus on
(but not be limited to)--
(i) creating healthier school environments, including
increasing healthy food options, physical activity
opportunities, promotion of healthy lifestyle, emotional
wellness, and prevention curricula, and activities to prevent
chronic diseases;
(ii) creating the infrastructure to support active living
and access to nutritious foods in a safe environment;
(iii) developing and promoting programs targeting a variety
of age levels to increase access to nutrition, physical
activity and smoking cessation, improve social and emotional
wellness, enhance safety in a community, or address any other
chronic disease priority area identified by the grantee;
(iv) assessing and implementing worksite wellness
programming and incentives;
(v) working to highlight healthy options at restaurants and
other food venues;
(vi) prioritizing strategies to reduce racial and ethnic
disparities, including social, economic, and geographic
determinants of health; and
(vii) addressing special populations needs, including all
age groups and individuals with disabilities, and individuals
in both urban and rural areas.
(3) Community-based prevention health activities.--
(A) In general.--An eligible entity shall use amounts
received under a grant under this section to implement a
variety of programs, policies, and infrastructure
improvements to promote healthier lifestyles.
(B) Activities.--An eligible entity shall implement
activities detailed in the community transformation plan
under paragraph (2).
(C) In-kind support.--An eligible entity may provide in-
kind resources such as staff, equipment, or office space in
carrying out activities under this section.
(4) Evaluation.--
(A) In general.--An eligible entity shall use amounts
provided under a grant under this section to conduct
activities to measure changes in the prevalence of chronic
disease risk factors among community members participating in
preventive health activities
(B) Types of measures.--In carrying out subparagraph (A),
the eligible entity shall, with respect to residents in the
community, measure--
(i) changes in weight;
(ii) changes in proper nutrition;
(iii) changes in physical activity;
(iv) changes in tobacco use prevalence;
(v) changes in emotional well-being and overall mental
health;
(vi) other factors using community-specific data from the
Behavioral Risk Factor Surveillance Survey; and
(vii) other factors as determined by the Secretary.
[[Page H2036]]
(C) Reporting.--An eligible entity shall annually submit to
the Director a report containing an evaluation of activities
carried out under the grant.
(5) Dissemination.--A grantee under this section shall--
(A) meet at least annually in regional or national meetings
to discuss challenges, best practices, and lessons learned
with respect to activities carried out under the grant; and
(B) develop models for the replication of successful
programs and activities and the mentoring of other eligible
entities.
(d) Training.--
(1) In general.--The Director shall develop a program to
provide training for eligible entities on effective
strategies for the prevention and control of chronic disease
and the link between physical, emotional, and social well-
being.
(2) Community transformation plan.--The Director shall
provide appropriate feedback and technical assistance to
grantees to establish community transformation plans
(3) Evaluation.--The Director shall provide a literature
review and framework for the evaluation of programs conducted
as part of the grant program under this section, in addition
to working with academic institutions or other entities with
expertise in outcome evaluation.
(e) Prohibition.--A grantee shall not use funds provided
under a grant under this section to create video games or to
carry out any other activities that may lead to higher rates
of obesity or inactivity.
(f) Authorization of Appropriations.--There are authorized
to be appropriated to carry out this section, such sums as
may be necessary for each fiscal years 2010 through 2014.
SEC. 4202. HEALTHY AGING, LIVING WELL; EVALUATION OF
COMMUNITY-BASED PREVENTION AND WELLNESS
PROGRAMS FOR MEDICARE BENEFICIARIES.
(a) Healthy Aging, Living Well.--
(1) In general.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary''), acting
through the Director of the Centers for Disease Control and
Prevention, shall award grants to State or local health
departments and Indian tribes to carry out 5-year pilot
programs to provide public health community interventions,
screenings, and where necessary, clinical referrals for
individuals who are between 55 and 64 years of age.
(2) Eligibility.--To be eligible to receive a grant under
paragraph (1), an entity shall--
(A) be--
(i) a State health department;
(ii) a local health department; or
(iii) an Indian tribe;
(B) submit to the Secretary an application at such time, in
such manner, and containing such information as the Secretary
may require including a description of the program to be
carried out under the grant;
(C) design a strategy for improving the health of the 55-
to-64 year-old population through community-based public
health interventions; and
(D) demonstrate the capacity, if funded, to develop the
relationships necessary with relevant health agencies, health
care providers, community-based organizations, and insurers
to carry out the activities described in paragraph (3), such
relationships to include the identification of a community-
based clinical partner, such as a community health center or
rural health clinic.
(3) Use of funds.--
(A) In general.--A State or local health department shall
use amounts received under a grant under this subsection to
carry out a program to provide the services described in this
paragraph to individuals who are between 55 and 64 years of
age.
(B) Public health interventions.--
(i) In general.--In developing and implementing such
activities, a grantee shall collaborate with the Centers for
Disease Control and Prevention and the Administration on
Aging, and relevant local agencies and organizations.
(ii) Types of intervention activities.--Intervention
activities conducted under this subparagraph may include
efforts to improve nutrition, increase physical activity,
reduce tobacco use and substance abuse, improve mental
health, and promote healthy lifestyles among the target
population.
(C) Community preventive screenings.--
(i) In general.--In addition to community-wide public
health interventions, a State or local health department
shall use amounts received under a grant under this
subsection to conduct ongoing health screening to identify
risk factors for cardiovascular disease, cancer, stroke, and
diabetes among individuals in both urban and rural areas who
are between 55 and 64 years of age.
(ii) Types of screening activities.--Screening activities
conducted under this subparagraph may include--
(I) mental health/behavioral health and substance use
disorders;
(II) physical activity, smoking, and nutrition; and
(III) any other measures deemed appropriate by the
Secretary.
(iii) Monitoring.--Grantees under this section shall
maintain records of screening results under this subparagraph
to establish the baseline data for monitoring the targeted
population
(D) Clinical referral/treatment for chronic diseases.--
(i) In general.--A State or local health department shall
use amounts received under a grant under this subsection to
ensure that individuals between 55 and 64 years of age who
are found to have chronic disease risk factors through the
screening activities described in subparagraph (C)(ii),
receive clinical referral/treatment for follow-up services to
reduce such risk.
(ii) Mechanism.--
(I) Identification and determination of status.--With
respect to each individual with risk factors for or having
heart disease, stroke, diabetes, or any other condition for
which such individual was screened under subparagraph (C), a
grantee under this section shall determine whether or not
such individual is covered under any public or private health
insurance program.
(II) Insured individuals.--An individual determined to be
covered under a health insurance program under subclause (I)
shall be referred by the grantee to the existing providers
under such program or, if such individual does not have a
current provider, to a provider who is in-network with
respect to the program involved.
(III) Uninsured individuals.--With respect to an individual
determined to be uninsured under subclause (I), the grantee's
community-based clinical partner described in paragraph
(4)(D) shall assist the individual in determining eligibility
for available public coverage options and identify other
appropriate community health care resources and assistance
programs.
(iii) Public health intervention program.--A State or local
health department shall use amounts received under a grant
under this subsection to enter into contracts with community
health centers or rural health clinics and mental health and
substance use disorder service providers to assist in the
referral/treatment of at risk patients to community resources
for clinical follow-up and help determine eligibility for
other public programs.
(E) Grantee evaluation.--An eligible entity shall use
amounts provided under a grant under this subsection to
conduct activities to measure changes in the prevalence of
chronic disease risk factors among participants.
(4) Pilot program evaluation.--The Secretary shall conduct
an annual evaluation of the effectiveness of the pilot
program under this subsection. In determining such
effectiveness, the Secretary shall consider changes in the
prevalence of uncontrolled chronic disease risk factors among
new Medicare enrollees (or individuals nearing enrollment,
including those who are 63 and 64 years of age) who reside in
States or localities receiving grants under this section as
compared with national and historical data for those States
and localities for the same population.
(5) Authorization of appropriations.--There are authorized
to be appropriated to carry out this subsection, such sums as
may be necessary for each of fiscal years 2010 through 2014.
(b) Evaluation and Plan for Community-Based Prevention and
Wellness Programs for Medicare Beneficiaries.--
(1) In general.--The Secretary shall conduct an evaluation
of community-based prevention and wellness programs and
develop a plan for promoting healthy lifestyles and chronic
disease self-management for Medicare beneficiaries.
(2) Medicare evaluation of prevention and wellness
programs.--
(A) In general.--The Secretary shall evaluate community
prevention and wellness programs including those that are
sponsored by the Administration on Aging, are evidence-based,
and have demonstrated potential to help Medicare
beneficiaries (particularly beneficiaries that have attained
65 years of age) reduce their risk of disease, disability,
and injury by making healthy lifestyle choices, including
exercise, diet, and self-management of chronic diseases.
(B) Evaluation.--The evaluation under subparagraph (A)
shall consist of the following:
(i) Evidence review.--The Secretary shall review available
evidence, literature, best practices, and resources that are
relevant to programs that promote healthy lifestyles and
reduce risk factors for the Medicare population. The
Secretary may determine the scope of the evidence review and
such issues to be considered, which shall include, at a
minimum--
(I) physical activity, nutrition, and obesity;
(II) falls;
(III) chronic disease self-management; and
(IV) mental health.
(ii) Independent evaluation of evidence-based community
prevention and wellness programs.--The Administrator of the
Centers for Medicare & Medicaid Services, in consultation
with the Assistant Secretary for Aging, shall, to the extent
feasible and practicable, conduct an evaluation of existing
community prevention and wellness programs that are sponsored
by the Administration on Aging to assess the extent to which
Medicare beneficiaries who participate in such programs--
(I) reduce their health risks, improve their health
outcomes, and adopt and maintain healthy behaviors;
(II) improve their ability to manage their chronic
conditions; and
(III) reduce their utilization of health services and
associated costs under the Medicare program for conditions
that are amenable to improvement under such programs.
(3) Report.--Not later than September 30, 2013, the
Secretary shall submit to Congress a report that includes--
(A) recommendations for such legislation and administrative
action as the Secretary determines appropriate to promote
healthy lifestyles and chronic disease self-management for
Medicare beneficiaries;
(B) any relevant findings relating to the evidence review
under paragraph (2)(B)(i); and
(C) the results of the evaluation under paragraph
(2)(B)(ii).
(4) Funding.--For purposes of carrying out this subsection,
the Secretary shall provide for the transfer, from the
Federal Hospital Insurance Trust Fund under section 1817 of
the Social Security Act (42 U.S.C. 1395i) and the Federal
Supplemental Medical Insurance Trust Fund under section 1841
of such Act (42 U.S.C. 1395t), in such proportion as the
Secretary determines appropriate, of $50,000,000 to the
Centers for Medicare & Medicaid Services Program Management
Account. Amounts transferred under the preceding sentence
shall remain available until expended.
[[Page H2037]]
(5) Administration.--Chapter 35 of title 44, United States
Code shall not apply to the this subsection.
(6) Medicare beneficiary.--In this subsection, the term
``Medicare beneficiary'' means an individual who is entitled
to benefits under part A of title XVIII of the Social
Security Act and enrolled under part B of such title.
SEC. 4203. REMOVING BARRIERS AND IMPROVING ACCESS TO WELLNESS
FOR INDIVIDUALS WITH DISABILITIES.
Title V of the Rehabilitation Act of 1973 (29 U.S.C. 791 et
seq.) is amended by adding at the end of the following:
``SEC. 510. ESTABLISHMENT OF STANDARDS FOR ACCESSIBLE MEDICAL
DIAGNOSTIC EQUIPMENT.
``(a) Standards.--Not later than 24 months after the date
of enactment of the Affordable Health Choices Act, the
Architectural and Transportation Barriers Compliance Board
shall, in consultation with the Commissioner of the Food and
Drug Administration, promulgate regulatory standards in
accordance with the Administrative Procedure Act (2 U.S.C.
551 et seq.) setting forth the minimum technical criteria for
medical diagnostic equipment used in (or in conjunction with)
physician's offices, clinics, emergency rooms, hospitals, and
other medical settings. The standards shall ensure that such
equipment is accessible to, and usable by, individuals with
accessibility needs, and shall allow independent entry to,
use of, and exit from the equipment by such individuals to
the maximum extent possible.
``(b) Medical Diagnostic Equipment Covered.--The standards
issued under subsection (a) for medical diagnostic equipment
shall apply to equipment that includes examination tables,
examination chairs (including chairs used for eye
examinations or procedures, and dental examinations or
procedures), weight scales, mammography equipment, x-ray
machines, and other radiological equipment commonly used for
diagnostic purposes by health professionals.
``(c) Review and Amendment.--The Architectural and
Transportation Barriers Compliance Board, in consultation
with the Commissioner of the Food and Drug Administration,
shall periodically review and, as appropriate, amend the
standards in accordance with the Administrative Procedure Act
(2 U.S.C. 551 et seq.).''.
SEC. 4204. IMMUNIZATIONS.
(a) State Authority To Purchase Recommended Vaccines for
Adults.--Section 317 of the Public Health Service Act (42
U.S.C. 247b) is amended by adding at the end the following:
``(l) Authority To Purchase Recommended Vaccines for
Adults.--
``(1) In general.--The Secretary may negotiate and enter
into contracts with manufacturers of vaccines for the
purchase and delivery of vaccines for adults as provided for
under subsection (e).
``(2) State purchase.--A State may obtain additional
quantities of such adult vaccines (subject to amounts
specified to the Secretary by the State in advance of
negotiations) through the purchase of vaccines from
manufacturers at the applicable price negotiated by the
Secretary under this subsection.''.
(b) Demonstration Program To Improve Immunization
Coverage.--Section 317 of the Public Health Service Act (42
U.S.C. 247b), as amended by subsection (a), is further
amended by adding at the end the following:
``(m) Demonstration Program To Improve Immunization
Coverage.--
``(1) In general.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall establish a demonstration program to award grants to
States to improve the provision of recommended immunizations
for children, adolescents, and adults through the use of
evidence-based, population-based interventions for high-risk
populations.
``(2) State plan.--To be eligible for a grant under
paragraph (1), a State shall submit to the Secretary an
application at such time, in such manner, and containing such
information as the Secretary may require, including a State
plan that describes the interventions to be implemented under
the grant and how such interventions match with local needs
and capabilities, as determined through consultation with
local authorities.
``(3) Use of funds.--Funds received under a grant under
this subsection shall be used to implement interventions that
are recommended by the Task Force on Community Preventive
Services (as established by the Secretary, acting through the
Director of the Centers for Disease Control and Prevention)
or other evidence-based interventions, including--
``(A) providing immunization reminders or recalls for
target populations of clients, patients, and consumers;
``(B) educating targeted populations and health care
providers concerning immunizations in combination with one or
more other interventions;
``(C) reducing out-of-pocket costs for families for
vaccines and their administration;
``(D) carrying out immunization-promoting strategies for
participants or clients of public programs, including
assessments of immunization status, referrals to health care
providers, education, provision of on-site immunizations, or
incentives for immunization;
``(E) providing for home visits that promote immunization
through education, assessments of need, referrals, provision
of immunizations, or other services;
``(F) providing reminders or recalls for immunization
providers;
``(G) conducting assessments of, and providing feedback to,
immunization providers;
``(H) any combination of one or more interventions
described in this paragraph; or
``(I) immunization information systems to allow all States
to have electronic databases for immunization records.
``(4) Consideration.--In awarding grants under this
subsection, the Secretary shall consider any reviews or
recommendations of the Task Force on Community Preventive
Services.
``(5) Evaluation.--Not later than 3 years after the date on
which a State receives a grant under this subsection, the
State shall submit to the Secretary an evaluation of progress
made toward improving immunization coverage rates among high-
risk populations within the State.
``(6) Report to congress.--Not later than 4 years after the
date of enactment of the Affordable Health Choices Act, the
Secretary shall submit to Congress a report concerning the
effectiveness of the demonstration program established under
this subsection together with recommendations on whether to
continue and expand such program.
``(7) Authorization of appropriations.--There is authorized
to be appropriated to carry out this subsection, such sums as
may be necessary for each of fiscal years 2010 through
2014.''.
(c) Reauthorization of Immunization Program.--Section
317(j) of the Public Health Service Act (42 U.S.C. 247b(j))
is amended--
(1) in paragraph (1), by striking ``for each of the fiscal
years 1998 through 2005''; and
(2) in paragraph (2), by striking ``after October 1,
1997,''.
(d) Rule of Construction Regarding Access to
Immunizations.--Nothing in this section (including the
amendments made by this section), or any other provision of
this Act (including any amendments made by this Act) shall be
construed to decrease children's access to immunizations.
(e) GAO Study and Report on Medicare Beneficiary Access to
Vaccines.--
(1) Study.--The Comptroller General of the United States
(in this section referred to as the ``Comptroller General'')
shall conduct a study on the ability of Medicare
beneficiaries who were 65 years of age or older to access
routinely recommended vaccines covered under the prescription
drug program under part D of title XVIII of the Social
Security Act over the period since the establishment of such
program. Such study shall include the following:
(A) An analysis and determination of--
(i) the number of Medicare beneficiaries who were 65 years
of age or older and were eligible for a routinely recommended
vaccination that was covered under part D;
(ii) the number of such beneficiaries who actually received
a routinely recommended vaccination that was covered under
part D; and
(iii) any barriers to access by such beneficiaries to
routinely recommended vaccinations that were covered under
part D.
(B) A summary of the findings and recommendations by
government agencies, departments, and advisory bodies (as
well as relevant professional organizations) on the impact of
coverage under part D of routinely recommended adult
immunizations for access to such immunizations by Medicare
beneficiaries.
(2) Report.--Not later than June 1, 2011, the Comptroller
General shall submit to the appropriate committees of
jurisdiction of the House of Representatives and the Senate a
report containing the results of the study conducted under
paragraph (1), together with recommendations for such
legislation and administrative action as the Comptroller
General determines appropriate.
(3) Funding.--Out of any funds in the Treasury not
otherwise appropriated, there are appropriated $1,000,000 for
fiscal year 2010 to carry out this subsection.
SEC. 4205. NUTRITION LABELING OF STANDARD MENU ITEMS AT CHAIN
RESTAURANTS.
(a) Technical Amendments.--Section 403(q)(5)(A) of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)(A))
is amended--
(1) in subitem (i), by inserting at the beginning ``except
as provided in clause (H)(ii)(III),''; and
(2) in subitem (ii), by inserting at the beginning ``except
as provided in clause (H)(ii)(III),''.
(b) Labeling Requirements.--Section 403(q)(5) of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)) is
amended by adding at the end the following:
``(H) Restaurants, Retail Food Establishments, and Vending
Machines.--
``(i) General requirements for restaurants and similar
retail food establishments.--Except for food described in
subclause (vii), in the case of food that is a standard menu
item that is offered for sale in a restaurant or similar
retail food establishment that is part of a chain with 20 or
more locations doing business under the same name (regardless
of the type of ownership of the locations) and offering for
sale substantially the same menu items, the restaurant or
similar retail food establishment shall disclose the
information described in subclauses (ii) and (iii).
``(ii) Information required to be disclosed by restaurants
and retail food establishments.--Except as provided in
subclause (vii), the restaurant or similar retail food
establishment shall disclose in a clear and conspicuous
manner--
``(I)(aa) in a nutrient content disclosure statement
adjacent to the name of the standard menu item, so as to be
clearly associated with the standard menu item, on the menu
listing the item for sale, the number of calories contained
in the standard menu item, as usually prepared and offered
for sale; and
``(bb) a succinct statement concerning suggested daily
caloric intake, as specified by the Secretary by regulation
and posted prominently on the menu and designed to enable the
public to understand, in the context of a total daily diet,
the significance of the caloric information that is provided
on the menu;
``(II)(aa) in a nutrient content disclosure statement
adjacent to the name of the standard menu item, so as to be
clearly associated with
[[Page H2038]]
the standard menu item, on the menu board, including a drive-
through menu board, the number of calories contained in the
standard menu item, as usually prepared and offered for sale;
and
``(bb) a succinct statement concerning suggested daily
caloric intake, as specified by the Secretary by regulation
and posted prominently on the menu board, designed to enable
the public to understand, in the context of a total daily
diet, the significance of the nutrition information that is
provided on the menu board;
``(III) in a written form, available on the premises of the
restaurant or similar retail establishment and to the
consumer upon request, the nutrition information required
under clauses (C) and (D) of subparagraph (1); and
``(IV) on the menu or menu board, a prominent, clear, and
conspicuous statement regarding the availability of the
information described in item (III).
``(iii) Self-service food and food on display.--Except as
provided in subclause (vii), in the case of food sold at a
salad bar, buffet line, cafeteria line, or similar self-
service facility, and for self-service beverages or food that
is on display and that is visible to customers, a restaurant
or similar retail food establishment shall place adjacent to
each food offered a sign that lists calories per displayed
food item or per serving.
``(iv) Reasonable basis.--For the purposes of this clause,
a restaurant or similar retail food establishment shall have
a reasonable basis for its nutrient content disclosures,
including nutrient databases, cookbooks, laboratory analyses,
and other reasonable means, as described in section 101.10 of
title 21, Code of Federal Regulations (or any successor
regulation) or in a related guidance of the Food and Drug
Administration.
``(v) Menu variability and combination meals.--The
Secretary shall establish by regulation standards for
determining and disclosing the nutrient content for standard
menu items that come in different flavors, varieties, or
combinations, but which are listed as a single menu item,
such as soft drinks, ice cream, pizza, doughnuts, or
children's combination meals, through means determined by the
Secretary, including ranges, averages, or other methods.
``(vi) Additional information.--If the Secretary determines
that a nutrient, other than a nutrient required under
subclause (ii)(III), should be disclosed for the purpose of
providing information to assist consumers in maintaining
healthy dietary practices, the Secretary may require, by
regulation, disclosure of such nutrient in the written form
required under subclause (ii)(III).
``(vii) Nonapplicability to certain food.--
``(I) In general.--Subclauses (i) through (vi) do not apply
to--
``(aa) items that are not listed on a menu or menu board
(such as condiments and other items placed on the table or
counter for general use);
``(bb) daily specials, temporary menu items appearing on
the menu for less than 60 days per calendar year, or custom
orders; or
``(cc) such other food that is part of a customary market
test appearing on the menu for less than 90 days, under terms
and conditions established by the Secretary.
``(II) Written forms.--Subparagraph (5)(C) shall apply to
any regulations promulgated under subclauses (ii)(III) and
(vi).
``(viii) Vending machines.--
``(I) In general.--In the case of an article of food sold
from a vending machine that--
``(aa) does not permit a prospective purchaser to examine
the Nutrition Facts Panel before purchasing the article or
does not otherwise provide visible nutrition information at
the point of purchase; and
``(bb) is operated by a person who is engaged in the
business of owning or operating 20 or more vending machines,
the vending machine operator shall provide a sign in close
proximity to each article of food or the selection button
that includes a clear and conspicuous statement disclosing
the number of calories contained in the article.
``(ix) Voluntary provision of nutrition information.--
``(I) In general.--An authorized official of any restaurant
or similar retail food establishment or vending machine
operator not subject to the requirements of this clause may
elect to be subject to the requirements of such clause, by
registering biannually the name and address of such
restaurant or similar retail food establishment or vending
machine operator with the Secretary, as specified by the
Secretary by regulation.
``(II) Registration.--Within 120 days of enactment of this
clause, the Secretary shall publish a notice in the Federal
Register specifying the terms and conditions for
implementation of item (I), pending promulgation of
regulations.
``(III) Rule of construction.--Nothing in this subclause
shall be construed to authorize the Secretary to require an
application, review, or licensing process for any entity to
register with the Secretary, as described in such item.
``(x) Regulations.--
``(I) Proposed regulation.--Not later than 1 year after the
date of enactment of this clause, the Secretary shall
promulgate proposed regulations to carry out this clause.
``(II) Contents.--In promulgating regulations, the
Secretary shall--
``(aa) consider standardization of recipes and methods of
preparation, reasonable variation in serving size and
formulation of menu items, space on menus and menu boards,
inadvertent human error, training of food service workers,
variations in ingredients, and other factors, as the
Secretary determines; and
``(bb) specify the format and manner of the nutrient
content disclosure requirements under this subclause.
``(III) Reporting.--The Secretary shall submit to the
Committee on Health, Education, Labor, and Pensions of the
Senate and the Committee on Energy and Commerce of the House
of Representatives a quarterly report that describes the
Secretary's progress toward promulgating final regulations
under this subparagraph.
``(xi) Definition.--In this clause, the term `menu' or
`menu board' means the primary writing of the restaurant or
other similar retail food establishment from which a consumer
makes an order selection.''
(c) National Uniformity.--Section 403A(a)(4) of the Federal
Food, Drug, and Cosmetic Act (21 U.S.C. 343-1(a)(4)) is
amended by striking ``except a requirement for nutrition
labeling of food which is exempt under subclause (i) or (ii)
of section 403(q)(5)(A)'' and inserting ``except that this
paragraph does not apply to food that is offered for sale in
a restaurant or similar retail food establishment that is not
part of a chain with 20 or more locations doing business
under the same name (regardless of the type of ownership of
the locations) and offering for sale substantially the same
menu items unless such restaurant or similar retail food
establishment complies with the voluntary provision of
nutrition information requirements under section
403(q)(5)(H)(ix)''.
(d) Rule of Construction.--Nothing in the amendments made
by this section shall be construed--
(1) to preempt any provision of State or local law, unless
such provision establishes or continues into effect nutrient
content disclosures of the type required under section
403(q)(5)(H) of the Federal Food, Drug, and Cosmetic Act (as
added by subsection (b)) and is expressly preempted under
subsection (a)(4) of such section;
(2) to apply to any State or local requirement respecting a
statement in the labeling of food that provides for a warning
concerning the safety of the food or component of the food;
or
(3) except as provided in section 403(q)(5)(H)(ix) of the
Federal Food, Drug, and Cosmetic Act (as added by subsection
(b)), to apply to any restaurant or similar retail food
establishment other than a restaurant or similar retail food
establishment described in section 403(q)(5)(H)(i) of such
Act.
SEC. 4206. DEMONSTRATION PROJECT CONCERNING INDIVIDUALIZED
WELLNESS PLAN.
Section 330 of the Public Health Service Act (42 U.S.C.
245b) is amended by adding at the end the following:
``(s) Demonstration Program for Individualized Wellness
Plans.--
``(1) In general.--The Secretary shall establish a pilot
program to test the impact of providing at-risk populations
who utilize community health centers funded under this
section an individualized wellness plan that is designed to
reduce risk factors for preventable conditions as identified
by a comprehensive risk-factor assessment.
``(2) Agreements.--The Secretary shall enter into
agreements with not more than 10 community health centers
funded under this section to conduct activities under the
pilot program under paragraph (1).
``(3) Wellness plans.--
``(A) In general.--An individualized wellness plan prepared
under the pilot program under this subsection may include one
or more of the following as appropriate to the individual's
identified risk factors:
``(i) Nutritional counseling.
``(ii) A physical activity plan.
``(iii) Alcohol and smoking cessation counseling and
services.
``(iv) Stress management.
``(v) Dietary supplements that have health claims approved
by the Secretary.
``(vi) Compliance assistance provided by a community health
center employee.
``(B) Risk factors.--Wellness plan risk factors shall
include--
``(i) weight;
``(ii) tobacco and alcohol use;
``(iii) exercise rates;
``(iv) nutritional status; and
``(v) blood pressure.
``(C) Comparisons.--Individualized wellness plans shall
make comparisons between the individual involved and a
control group of individuals with respect to the risk factors
described in subparagraph (B).
``(4) Authorization of appropriations.--There is authorized
to be appropriated to carry out this subsection, such sums as
may be necessary.''.
SEC. 4207. REASONABLE BREAK TIME FOR NURSING MOTHERS.
Section 7 of the Fair Labor Standards Act of 1938 (29
U.S.C. 207) is amended by adding at the end the following:
``(r)(1) An employer shall provide--
``(A) a reasonable break time for an employee to express
breast milk for her nursing child for 1 year after the
child's birth each time such employee has need to express the
milk; and
``(B) a place, other than a bathroom, that is shielded from
view and free from intrusion from coworkers and the public,
which may be used by an employee to express breast milk.
``(2) An employer shall not be required to compensate an
employee receiving reasonable break time under paragraph (1)
for any work time spent for such purpose.
``(3) An employer that employs less than 50 employees shall
not be subject to the requirements of this subsection, if
such requirements would impose an undue hardship by causing
the employer significant difficulty or expense when
considered in relation to the size, financial resources,
nature, or structure of the employer's business.
``(4) Nothing in this subsection shall preempt a State law
that provides greater protections to employees than the
protections provided for under this subsection.''.
[[Page H2039]]
Subtitle D--Support for Prevention and Public Health Innovation
SEC. 4301. RESEARCH ON OPTIMIZING THE DELIVERY OF PUBLIC
HEALTH SERVICES.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary''), acting
through the Director of the Centers for Disease Control and
Prevention, shall provide funding for research in the area of
public health services and systems.
(b) Requirements of Research.--Research supported under
this section shall include--
(1) examining evidence-based practices relating to
prevention, with a particular focus on high priority areas as
identified by the Secretary in the National Prevention
Strategy or Healthy People 2020, and including comparing
community-based public health interventions in terms of
effectiveness and cost;
(2) analyzing the translation of interventions from
academic settings to real world settings; and
(3) identifying effective strategies for organizing,
financing, or delivering public health services in real world
community settings, including comparing State and local
health department structures and systems in terms of
effectiveness and cost.
(c) Existing Partnerships.--Research supported under this
section shall be coordinated with the Community Preventive
Services Task Force and carried out by building on existing
partnerships within the Federal Government while also
considering initiatives at the State and local levels and in
the private sector.
(d) Annual Report.--The Secretary shall, on an annual
basis, submit to Congress a report concerning the activities
and findings with respect to research supported under this
section.
SEC. 4302. UNDERSTANDING HEALTH DISPARITIES: DATA COLLECTION
AND ANALYSIS.
(a) Uniform Categories and Collection Requirements.--The
Public Health Service Act (42 U.S.C. 201 et seq.) is amended
by adding at the end the following:
``TITLE XXXI--DATA COLLECTION, ANALYSIS, AND QUALITY
``SEC. 3101. DATA COLLECTION, ANALYSIS, AND QUALITY.
``(a) Data Collection.--
``(1) In general.--The Secretary shall ensure that, by not
later than 2 years after the date of enactment of this title,
any federally conducted or supported health care or public
health program, activity or survey (including Current
Population Surveys and American Community Surveys conducted
by the Bureau of Labor Statistics and the Bureau of the
Census) collects and reports, to the extent practicable--
``(A) data on race, ethnicity, sex, primary language, and
disability status for applicants, recipients, or
participants;
``(B) data at the smallest geographic level such as State,
local, or institutional levels if such data can be
aggregated;
``(C) sufficient data to generate statistically reliable
estimates by racial, ethnic, sex, primary language, and
disability status subgroups for applicants, recipients or
participants using, if needed, statistical oversamples of
these subpopulations; and
``(D) any other demographic data as deemed appropriate by
the Secretary regarding health disparities.
``(2) Collection standards.--In collecting data described
in paragraph (1), the Secretary or designee shall--
``(A) use Office of Management and Budget standards, at a
minimum, for race and ethnicity measures;
``(B) develop standards for the measurement of sex, primary
language, and disability status;
``(C) develop standards for the collection of data
described in paragraph (1) that, at a minimum--
``(i) collects self-reported data by the applicant,
recipient, or participant; and
``(ii) collects data from a parent or legal guardian if the
applicant, recipient, or participant is a minor or legally
incapacitated;
``(D) survey health care providers and establish other
procedures in order to assess access to care and treatment
for individuals with disabilities and to identify--
``(i) locations where individuals with disabilities access
primary, acute (including intensive), and long-term care;
``(ii) the number of providers with accessible facilities
and equipment to meet the needs of the individuals with
disabilities, including medical diagnostic equipment that
meets the minimum technical criteria set forth in section 510
of the Rehabilitation Act of 1973; and
``(iii) the number of employees of health care providers
trained in disability awareness and patient care of
individuals with disabilities; and
``(E) require that any reporting requirement imposed for
purposes of measuring quality under any ongoing or federally
conducted or supported health care or public health program,
activity, or survey includes requirements for the collection
of data on individuals receiving health care items or
services under such programs activities by race, ethnicity,
sex, primary language, and disability status.
``(3) Data management.--In collecting data described in
paragraph (1), the Secretary, acting through the National
Coordinator for Health Information Technology shall--
``(A) develop national standards for the management of data
collected; and
``(B) develop interoperability and security systems for
data management.
``(b) Data Analysis.--
``(1) In general.--For each federally conducted or
supported health care or public health program or activity,
the Secretary shall analyze data collected under paragraph
(a) to detect and monitor trends in health disparities (as
defined for purposes of section 485E) at the Federal and
State levels.
``(c) Data Reporting and Dissemination.--
``(1) In general.--The Secretary shall make the analyses
described in (b) available to--
``(A) the Office of Minority Health;
``(B) the National Center on Minority Health and Health
Disparities;
``(C) the Agency for Healthcare Research and Quality;
``(D) the Centers for Disease Control and Prevention;
``(E) the Centers for Medicare & Medicaid Services;
``(F) the Indian Health Service and epidemiology centers
funded under the Indian Health Care Improvement Act;
``(G) the Office of Rural health;
``(H) other agencies within the Department of Health and
Human Services; and
``(I) other entities as determined appropriate by the
Secretary.
``(2) Reporting of data.--The Secretary shall report data
and analyses described in (a) and (b) through--
``(A) public postings on the Internet websites of the
Department of Health and Human Services; and
``(B) any other reporting or dissemination mechanisms
determined appropriate by the Secretary.
``(3) Availability of data.--The Secretary may make data
described in (a) and (b) available for additional research,
analyses, and dissemination to other Federal agencies, non-
governmental entities, and the public, in accordance with any
Federal agency's data user agreements.
``(d) Limitations on Use of Data.--Nothing in this section
shall be construed to permit the use of information collected
under this section in a manner that would adversely affect
any individual.
``(e) Protection and Sharing of Data.--
``(1) Privacy and other safeguards.--The Secretary shall
ensure (through the promulgation of regulations or otherwise)
that--
``(A) all data collected pursuant to subsection (a) is
protected--
``(i) under privacy protections that are at least as broad
as those that the Secretary applies to other health data
under the regulations promulgated under section 264(c) of the
Health Insurance Portability and Accountability Act of 1996
(Public Law 104-191; 110 Stat. 2033); and
``(ii) from all inappropriate internal use by any entity
that collects, stores, or receives the data, including use of
such data in determinations of eligibility (or continued
eligibility) in health plans, and from other inappropriate
uses, as defined by the Secretary; and
``(B) all appropriate information security safeguards are
used in the collection, analysis, and sharing of data
collected pursuant to subsection (a).
``(2) Data sharing.--The Secretary shall establish
procedures for sharing data collected pursuant to subsection
(a), measures relating to such data, and analyses of such
data, with other relevant Federal and State agencies
including the agencies, centers, and entities within the
Department of Health and Human Services specified in
subsection (c)(1).
``(f) Data on Rural Underserved Populations.--The Secretary
shall ensure that any data collected in accordance with this
section regarding racial and ethnic minority groups are also
collected regarding underserved rural and frontier
populations.
``(g) Authorization of Appropriations.--For the purpose of
carrying out this section, there are authorized to be
appropriated such sums as may be necessary for each of fiscal
years 2010 through 2014.
``(h) Requirement for Implementation.--Notwithstanding any
other provision of this section, data may not be collected
under this section unless funds are directly appropriated for
such purpose in an appropriations Act.
``(i) Consultation.--The Secretary shall consult with the
Director of the Office of Personnel Management, the Secretary
of Defense, the Secretary of Veterans Affairs, the Director
of the Bureau of the Census, the Commissioner of Social
Security, and the head of other appropriate Federal agencies
in carrying out this section.''.
(b) Addressing Health Care Disparities in Medicaid and
CHIP.--
(1) Standardized collection requirements included in state
plans.--
(A) Medicaid.--Section 1902(a) of the Social Security Act
(42 U.S.C. 1396a(a)), as amended by section 2001(d), is
amended--
(i) in paragraph 4), by striking ``and'' at the end;
(ii) in paragraph (75), by striking the period at the end
and inserting ``; and''; and
(iii) by inserting after paragraph (75) the following new
paragraph:
``(76) provide that any data collected under the State plan
meets the requirements of section 3101 of the Public Health
Service Act.''.
(B) CHIP.--Section 2108(e) of the Social Security Act (42
U.S.C. 1397hh(e)) is amended by adding at the end the
following new paragraph:
``(7) Data collected and reported in accordance with
section 3101 of the Public Health Service Act, with respect
to individuals enrolled in the State child health plan (and,
in the case of enrollees under 19 years of age, their parents
or legal guardians), including data regarding the primary
language of such individuals, parents, and legal
guardians.''.
(2) Extending medicare requirement to address health
disparities data collection to medicaid and chip.--Title XIX
of the Social Security Act (42 U.S.C. 1396 et seq.), as
amended by section 2703 is amended by adding at the end the
following new section:
``SEC. 1946. ADDRESSING HEALTH CARE DISPARITIES.
``(a) Evaluating Data Collection Approaches.--The Secretary
shall evaluate approaches for the collection of data under
this title and title XXI, to be performed in conjunction with
existing quality reporting requirements
[[Page H2040]]
and programs under this title and title XXI, that allow for
the ongoing, accurate, and timely collection and evaluation
of data on disparities in health care services and
performance on the basis of race, ethnicity, sex, primary
language, and disability status. In conducting such
evaluation, the Secretary shall consider the following
objectives:
``(1) Protecting patient privacy.
``(2) Minimizing the administrative burdens of data
collection and reporting on States, providers, and health
plans participating under this title or title XXI.
``(3) Improving program data under this title and title XXI
on race, ethnicity, sex, primary language, and disability
status.
``(b) Reports to Congress.--
``(1) Report on evaluation.--Not later than 18 months after
the date of the enactment of this section, the Secretary
shall submit to Congress a report on the evaluation conducted
under subsection (a). Such report shall, taking into
consideration the results of such evaluation--
``(A) identify approaches (including defining
methodologies) for identifying and collecting and evaluating
data on health care disparities on the basis of race,
ethnicity, sex, primary language, and disability status for
the programs under this title and title XXI; and
``(B) include recommendations on the most effective
strategies and approaches to reporting HEDIS quality measures
as required under section 1852(e)(3) and other nationally
recognized quality performance measures, as appropriate, on
such bases.
``(2) Reports on data analyses.--Not later than 4 years
after the date of the enactment of this section, and 4 years
thereafter, the Secretary shall submit to Congress a report
that includes recommendations for improving the
identification of health care disparities for beneficiaries
under this title and under title XXI based on analyses of the
data collected under subsection (c).
``(c) Implementing Effective Approaches.--Not later than 24
months after the date of the enactment of this section, the
Secretary shall implement the approaches identified in the
report submitted under subsection (b)(1) for the ongoing,
accurate, and timely collection and evaluation of data on
health care disparities on the basis of race, ethnicity, sex,
primary language, and disability status.''.
SEC. 4303. CDC AND EMPLOYER-BASED WELLNESS PROGRAMS.
Title III of the Public Health Service Act (42 U.S.C. 241
et seq.), by section 4102, is further amended by adding at
the end the following:
``PART U--EMPLOYER-BASED WELLNESS PROGRAM
``SEC. 399MM. TECHNICAL ASSISTANCE FOR EMPLOYER-BASED
WELLNESS PROGRAMS.
``In order to expand the utilization of evidence-based
prevention and health promotion approaches in the workplace,
the Director shall--
``(1) provide employers (including small, medium, and large
employers, as determined by the Director) with technical
assistance, consultation, tools, and other resources in
evaluating such employers' employer-based wellness programs,
including--
``(A) measuring the participation and methods to increase
participation of employees in such programs;
``(B) developing standardized measures that assess policy,
environmental and systems changes necessary to have a
positive health impact on employees' health behaviors, health
outcomes, and health care expenditures; and
``(C) evaluating such programs as they relate to changes in
the health status of employees, the absenteeism of employees,
the productivity of employees, the rate of workplace injury,
and the medical costs incurred by employees; and
``(2) build evaluation capacity among workplace staff by
training employers on how to evaluate employer-based wellness
programs by ensuring evaluation resources, technical
assistance, and consultation are available to workplace staff
as needed through such mechanisms as web portals, call
centers, or other means.
``SEC. 399MM-1. NATIONAL WORKSITE HEALTH POLICIES AND
PROGRAMS STUDY.
``(a) In General.--In order to assess, analyze, and monitor
over time data about workplace policies and programs, and to
develop instruments to assess and evaluate comprehensive
workplace chronic disease prevention and health promotion
programs, policies and practices, not later than 2 years
after the date of enactment of this part, and at regular
intervals (to be determined by the Director) thereafter, the
Director shall conduct a national worksite health policies
and programs survey to assess employer-based health policies
and programs.
``(b) Report.--Upon the completion of each study under
subsection (a), the Director shall submit to Congress a
report that includes the recommendations of the Director for
the implementation of effective employer-based health
policies and programs.
``SEC. 399MM-2. PRIORITIZATION OF EVALUATION BY SECRETARY.
``The Secretary shall evaluate, in accordance with this
part, all programs funded through the Centers for Disease
Control and Prevention before conducting such an evaluation
of privately funded programs unless an entity with a
privately funded wellness program requests such an
evaluation.
``SEC. 399MM-3. PROHIBITION OF FEDERAL WORKPLACE WELLNESS
REQUIREMENTS.
``Notwithstanding any other provision of this part, any
recommendations, data, or assessments carried out under this
part shall not be used to mandate requirements for workplace
wellness programs.''.
SEC. 4304. EPIDEMIOLOGY-LABORATORY CAPACITY GRANTS.
Title XXVIII of the Public Health Service Act (42 U.S.C.
300hh et seq.) is amended by adding at the end the following:
``Subtitle C--Strengthening Public Health Surveillance Systems
``SEC. 2821. EPIDEMIOLOGY-LABORATORY CAPACITY GRANTS.
``(a) In General.--Subject to the availability of
appropriations, the Secretary, acting through the Director of
the Centers for Disease Control and Prevention, shall
establish an Epidemiology and Laboratory Capacity Grant
Program to award grants to State health departments as well
as local health departments and tribal jurisdictions that
meet such criteria as the Director determines appropriate.
Academic centers that assist State and eligible local and
tribal health departments may also be eligible for funding
under this section as the Director determines appropriate.
Grants shall be awarded under this section to assist public
health agencies in improving surveillance for, and response
to, infectious diseases and other conditions of public health
importance by--
``(1) strengthening epidemiologic capacity to identify and
monitor the occurrence of infectious diseases and other
conditions of public health importance;
``(2) enhancing laboratory practice as well as systems to
report test orders and results electronically;
``(3) improving information systems including developing
and maintaining an information exchange using national
guidelines and complying with capacities and functions
determined by an advisory council established and appointed
by the Director; and
``(4) developing and implementing prevention and control
strategies.
``(b) Authorization of Appropriations.--There are
authorized to be appropriated to carry out this section
$190,000,000 for each of fiscal years 2010 through 2013, of
which--
``(1) not less than $95,000,000 shall be made available
each such fiscal year for activities under paragraphs (1) and
(4) of subsection (a);
``(2) not less than $60,000,000 shall be made available
each such fiscal year for activities under subsection (a)(3);
and
``(3) not less than $32,000,000 shall be made available
each such fiscal year for activities under subsection
(a)(2).''.
SEC. 4305. ADVANCING RESEARCH AND TREATMENT FOR PAIN CARE
MANAGEMENT.
(a) Institute of Medicine Conference on Pain.--
(1) Convening.--Not later than 1 year after funds are
appropriated to carry out this subsection, the Secretary of
Health and Human Services shall seek to enter into an
agreement with the Institute of Medicine of the National
Academies to convene a Conference on Pain (in this subsection
referred to as ``the Conference'').
(2) Purposes.--The purposes of the Conference shall be to--
(A) increase the recognition of pain as a significant
public health problem in the United States;
(B) evaluate the adequacy of assessment, diagnosis,
treatment, and management of acute and chronic pain in the
general population, and in identified racial, ethnic, gender,
age, and other demographic groups that may be
disproportionately affected by inadequacies in the
assessment, diagnosis, treatment, and management of pain;
(C) identify barriers to appropriate pain care;
(D) establish an agenda for action in both the public and
private sectors that will reduce such barriers and
significantly improve the state of pain care research,
education, and clinical care in the United States.
(3) Other appropriate entity.--If the Institute of Medicine
declines to enter into an agreement under paragraph (1), the
Secretary of Health and Human Services may enter into such
agreement with another appropriate entity.
(4) Report.--A report summarizing the Conference's findings
and recommendations shall be submitted to the Congress not
later than June 30, 2011.
(5) Authorization of appropriations.--For the purpose of
carrying out this subsection, there is authorized to be
appropriated such sums as may be necessary for each of fiscal
years 2010 and 2011.
(b) Pain Research at National Institutes of Health.--Part B
of title IV of the Public Health Service Act (42 U.S.C. 284
et seq.) is amended by adding at the end the following:
``SEC. 409J. PAIN RESEARCH.
``(a) Research Initiatives.--
``(1) In general.--The Director of NIH is encouraged to
continue and expand, through the Pain Consortium, an
aggressive program of basic and clinical research on the
causes of and potential treatments for pain.
``(2) Annual recommendations.--Not less than annually, the
Pain Consortium, in consultation with the Division of Program
Coordination, Planning, and Strategic Initiatives, shall
develop and submit to the Director of NIH recommendations on
appropriate pain research initiatives that could be
undertaken with funds reserved under section 402A(c)(1) for
the Common Fund or otherwise available for such initiatives.
``(3) Definition.--In this subsection, the term `Pain
Consortium' means the Pain Consortium of the National
Institutes of Health or a similar trans-National Institutes
of Health coordinating entity designated by the Secretary for
purposes of this subsection.
``(b) Interagency Pain Research Coordinating Committee.--
``(1) Establishment.--The Secretary shall establish not
later than 1 year after the date of the enactment of this
section and as necessary maintain a committee, to be known as
the Interagency Pain Research Coordinating Committee
[[Page H2041]]
(in this section referred to as the `Committee'), to
coordinate all efforts within the Department of Health and
Human Services and other Federal agencies that relate to pain
research.
``(2) Membership.--
``(A) In general.--The Committee shall be composed of the
following voting members:
``(i) Not more than 7 voting Federal representatives
appoint by the Secretary from agencies that conduct pain care
research and treatment.
``(ii) 12 additional voting members appointed under
subparagraph (B).
``(B) Additional members.--The Committee shall include
additional voting members appointed by the Secretary as
follows:
``(i) 6 non-Federal members shall be appointed from among
scientists, physicians, and other health professionals.
``(ii) 6 members shall be appointed from members of the
general public, who are representatives of leading research,
advocacy, and service organizations for individuals with
pain-related conditions.
``(C) Nonvoting members.--The Committee shall include such
nonvoting members as the Secretary determines to be
appropriate.
``(3) Chairperson.--The voting members of the Committee
shall select a chairperson from among such members. The
selection of a chairperson shall be subject to the approval
of the Director of NIH.
``(4) Meetings.--The Committee shall meet at the call of
the chairperson of the Committee or upon the request of the
Director of NIH, but in no case less often than once each
year.
``(5) Duties.--The Committee shall--
``(A) develop a summary of advances in pain care research
supported or conducted by the Federal agencies relevant to
the diagnosis, prevention, and treatment of pain and diseases
and disorders associated with pain;
``(B) identify critical gaps in basic and clinical research
on the symptoms and causes of pain;
``(C) make recommendations to ensure that the activities of
the National Institutes of Health and other Federal agencies
are free of unnecessary duplication of effort;
``(D) make recommendations on how best to disseminate
information on pain care; and
``(E) make recommendations on how to expand partnerships
between public entities and private entities to expand
collaborative, cross-cutting research.
``(6) Review.--The Secretary shall review the necessity of
the Committee at least once every 2 years.''.
(c) Pain Care Education and Training.--Part D of title VII
of the Public Health Service Act (42 U.S.C. 294 et seq.) is
amended by adding at the end the following new section:
``SEC. 759. PROGRAM FOR EDUCATION AND TRAINING IN PAIN CARE.
``(a) In General.--The Secretary may make awards of grants,
cooperative agreements, and contracts to health professions
schools, hospices, and other public and private entities for
the development and implementation of programs to provide
education and training to health care professionals in pain
care.
``(b) Certain Topics.--An award may be made under
subsection (a) only if the applicant for the award agrees
that the program carried out with the award will include
information and education on--
``(1) recognized means for assessing, diagnosing, treating,
and managing pain and related signs and symptoms, including
the medically appropriate use of controlled substances;
``(2) applicable laws, regulations, rules, and policies on
controlled substances, including the degree to which
misconceptions and concerns regarding such laws, regulations,
rules, and policies, or the enforcement thereof, may create
barriers to patient access to appropriate and effective pain
care;
``(3) interdisciplinary approaches to the delivery of pain
care, including delivery through specialized centers
providing comprehensive pain care treatment expertise;
``(4) cultural, linguistic, literacy, geographic, and other
barriers to care in underserved populations; and
``(5) recent findings, developments, and improvements in
the provision of pain care.
``(c) Evaluation of Programs.--The Secretary shall
(directly or through grants or contracts) provide for the
evaluation of programs implemented under subsection (a) in
order to determine the effect of such programs on knowledge
and practice of pain care.
``(d) Pain Care Defined.--For purposes of this section the
term `pain care' means the assessment, diagnosis, treatment,
or management of acute or chronic pain regardless of
causation or body location.
``(e) Authorization of Appropriations.--There is authorized
to be appropriated to carry out this section, such sums as
may be necessary for each of the fiscal years 2010 through
2012. Amounts appropriated under this subsection shall remain
available until expended.''.
SEC. 4306. FUNDING FOR CHILDHOOD OBESITY DEMONSTRATION
PROJECT.
Section 1139A(e)(8) of the Social Security Act (42 U.S.C.
1320b-9a(e)(8)) is amended to read as follows:
``(8) Appropriation.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to carry out
this subsection, $25,000,000 for the period of fiscal years
2010 through 2014.''.
Subtitle E--Miscellaneous Provisions
SEC. 4401. SENSE OF THE SENATE CONCERNING CBO SCORING.
(a) Finding.--The Senate finds that the costs of prevention
programs are difficult to estimate due in part because
prevention initiatives are hard to measure and results may
occur outside the 5 and 10 year budget windows.
(b) Sense of Congress.--It is the sense of the Senate that
Congress should work with the Congressional Budget Office to
develop better methodologies for scoring progress to be made
in prevention and wellness programs.
SEC. 4402. EFFECTIVENESS OF FEDERAL HEALTH AND WELLNESS
INITIATIVES.
To determine whether existing Federal health and wellness
initiatives are effective in achieving their stated goals,
the Secretary of Health and Human Services shall--
(1) conduct an evaluation of such programs as they relate
to changes in health status of the American public and
specifically on the health status of the Federal workforce,
including absenteeism of employees, the productivity of
employees, the rate of workplace injury, and the medical
costs incurred by employees, and health conditions, including
workplace fitness, healthy food and beverages, and incentives
in the Federal Employee Health Benefits Program; and
(2) submit to Congress a report concerning such evaluation,
which shall include conclusions concerning the reasons that
such existing programs have proven successful or not
successful and what factors contributed to such conclusions.
TITLE V--HEALTH CARE WORKFORCE
Subtitle A--Purpose and Definitions
SEC. 5001. PURPOSE.
The purpose of this title is to improve access to and the
delivery of health care services for all individuals,
particularly low income, underserved, uninsured, minority,
health disparity, and rural populations by--
(1) gathering and assessing comprehensive data in order for
the health care workforce to meet the health care needs of
individuals, including research on the supply, demand,
distribution, diversity, and skills needs of the health care
workforce;
(2) increasing the supply of a qualified health care
workforce to improve access to and the delivery of health
care services for all individuals;
(3) enhancing health care workforce education and training
to improve access to and the delivery of health care services
for all individuals; and
(4) providing support to the existing health care workforce
to improve access to and the delivery of health care services
for all individuals.
SEC. 5002. DEFINITIONS.
(a) This Title.--In this title:
(1) Allied health professional.--The term ``allied health
professional'' means an allied health professional as defined
in section 799B(5) of the Public Heath Service Act (42 U.S.C.
295p(5)) who--
(A) has graduated and received an allied health professions
degree or certificate from an institution of higher
education; and
(B) is employed with a Federal, State, local or tribal
public health agency, or in a setting where patients might
require health care services, including acute care
facilities, ambulatory care facilities, personal residences,
and other settings located in health professional shortage
areas, medically underserved areas, or medically underserved
populations, as recognized by the Secretary of Health and
Human Services.
(2) Health care career pathway.--The term ``healthcare
career pathway'' means a rigorous, engaging, and high quality
set of courses and services that--
(A) includes an articulated sequence of academic and career
courses, including 21st century skills;
(B) is aligned with the needs of healthcare industries in a
region or State;
(C) prepares students for entry into the full range of
postsecondary education options, including registered
apprenticeships, and careers;
(D) provides academic and career counseling in student-to-
counselor ratios that allow students to make informed
decisions about academic and career options;
(E) meets State academic standards, State requirements for
secondary school graduation and is aligned with requirements
for entry into postsecondary education, and applicable
industry standards; and
(F) leads to 2 or more credentials, including--
(i) a secondary school diploma; and
(ii) a postsecondary degree, an apprenticeship or other
occupational certification, a certificate, or a license.
(3) Institution of higher education.--The term
``institution of higher education'' has the meaning given the
term in sections 101 and 102 of the Higher Education Act of
1965 (20 U.S.C. 1001 and 1002).
(4) Low income individual, state workforce investment
board, and local workforce investment board.--
(A) Low-income individual.--The term ``low-income
individual'' has the meaning given that term in section 101
of the Workforce investment Act of 1998 (29 U.S.C. 2801).
(B) State workforce investment board; local workforce
investment board.--The terms ``State workforce investment
board'' and ``local workforce investment board'', refer to a
State workforce investment board established under section
111 of the Workforce Investment Act of 1998 (29 U.S.C. 2821)
and a local workforce investment board established under
section 117 of such Act (29 U.S.C. 2832), respectively.
(5) Postsecondary education.--The term ``postsecondary
education'' means--
(A) a 4-year program of instruction, or not less than a 1-
year program of instruction that is acceptable for credit
toward an associate or a baccalaureate degree, offered by an
institution of higher education; or
(B) a certificate or registered apprenticeship program at
the postsecondary level offered by an institution of higher
education or a non-profit educational institution.
(6) Registered apprenticeship program.--The term
``registered apprenticeship program'' means an industry
skills training program at
[[Page H2042]]
the postsecondary level that combines technical and
theoretical training through structure on the job learning
with related instruction (in a classroom or through distance
learning) while an individual is employed, working under the
direction of qualified personnel or a mentor, and earning
incremental wage increases aligned to enhance job
proficiency, resulting in the acquisition of a nationally
recognized and portable certificate, under a plan approved by
the Office of Apprenticeship or a State agency recognized by
the Department of Labor.
(b) Title VII of the Public Health Service Act.--Section
799B of the Public Health Service Act (42 U.S.C. 295p) is
amended--
(1) by striking paragraph (3) and inserting the following:
``(3) Physician assistant education program.--The term
`physician assistant education program' means an educational
program in a public or private institution in a State that--
``(A) has as its objective the education of individuals
who, upon completion of their studies in the program, be
qualified to provide primary care medical services with the
supervision of a physician; and
``(B) is accredited by the Accreditation Review Commission
on Education for the Physician Assistant.''; and
(2) by adding at the end the following:
``(12) Area health education center.--The term `area health
education center' means a public or nonprofit private
organization that has a cooperative agreement or contract in
effect with an entity that has received an award under
subsection (a)(1) or (a)(2) of section 751, satisfies the
requirements in section 751(d)(1), and has as one of its
principal functions the operation of an area health education
center. Appropriate organizations may include hospitals,
health organizations with accredited primary care training
programs, accredited physician assistant educational programs
associated with a college or university, and universities or
colleges not operating a school of medicine or osteopathic
medicine.
``(13) Area health education center program.--The term
`area health education center program' means cooperative
program consisting of an entity that has received an award
under subsection (a)(1) or (a)(2) of section 751 for the
purpose of planning, developing, operating, and evaluating an
area health education center program and one or more area
health education centers, which carries out the required
activities described in section 751(c), satisfies the program
requirements in such section, has as one of its principal
functions identifying and implementing strategies and
activities that address health care workforce needs in its
service area, in coordination with the local workforce
investment boards.
``(14) Clinical social worker.--The term `clinical social
worker' has the meaning given the term in section 1861(hh)(1)
of the Social Security Act (42 U.S.C. 1395x(hh)(1)).
``(15) Cultural competency.--The term `cultural competency'
shall be defined by the Secretary in a manner consistent with
section 1707(d)(3).
``(16) Direct care worker.--The term `direct care worker'
has the meaning given that term in the 2010 Standard
Occupational Classifications of the Department of Labor for
Home Health Aides [31-1011], Psychiatric Aides [31-1013],
Nursing Assistants [31-1014], and Personal Care Aides [39-
9021].
``(17) Federally qualified health center.--The term
`Federally qualified health center' has the meaning given
that term in section 1861(aa) of the Social Security Act (42
U.S.C. 1395x(aa)).
``(18) Frontier health professional shortage area.--The
term `frontier health professional shortage area' means an
area--
``(A) with a population density less than 6 persons per
square mile within the service area; and
``(B) with respect to which the distance or time for the
population to access care is excessive.
``(19) Graduate psychology.--The term `graduate psychology'
means an accredited program in professional psychology.
``(20) Health disparity population.--The term `health
disparity population' has the meaning given such term in
section 903(d)(1).
``(21) Health literacy.--The term `health literacy' means
the degree to which an individual has the capacity to obtain,
communicate, process, and understand health information and
services in order to make appropriate health decisions.
``(22) Mental health service professional.--The term
`mental health service professional' means an individual with
a graduate or postgraduate degree from an accredited
institution of higher education in psychiatry, psychology,
school psychology, behavioral pediatrics, psychiatric
nursing, social work, school social work, substance abuse
disorder prevention and treatment, marriage and family
counseling, school counseling, or professional counseling.
``(23) One-stop delivery system center.--The term `one-stop
delivery system' means a one-stop delivery system described
in section 134(c) of the Workforce Investment Act of 1998 (29
U.S.C. 2864(c)).
``(24) Paraprofessional child and adolescent mental health
worker.--The term `paraprofessional child and adolescent
mental health worker' means an individual who is not a mental
or behavioral health service professional, but who works at
the first stage of contact with children and families who are
seeking mental or behavioral health services, including
substance abuse prevention and treatment services.
``(25) Racial and ethnic minority group; racial and ethnic
minority population.--The terms `racial and ethnic minority
group' and `racial and ethnic minority population' have the
meaning given the term `racial and ethnic minority group' in
section 1707.
``(26) Rural health clinic.--The term `rural health clinic'
has the meaning given that term in section 1861(aa) of the
Social Security Act (42 U.S.C. 1395x(aa)).''.
(c) Title VIII of the Public Health Service Act.--Section
801 of the Public Health Service Act (42 U.S.C. 296) is
amended--
(1) in paragraph (2)--
(A) by striking ``means a'' and inserting ``means an
accredited (as defined in paragraph 6)''; and
(B) by striking the period as inserting the following:
``where graduates are--
``(A) authorized to sit for the National Council Licensure
EXamination-Registered Nurse (NCLEX-RN); or
``(B) licensed registered nurses who will receive a
graduate or equivalent degree or training to become an
advanced education nurse as defined by section 811(b).''; and
(2) by adding at the end the following:
``(16) Accelerated nursing degree program.--The term
`accelerated nursing degree program' means a program of
education in professional nursing offered by an accredited
school of nursing in which an individual holding a bachelors
degree in another discipline receives a BSN or MSN degree in
an accelerated time frame as determined by the accredited
school of nursing.
``(17) Bridge or degree completion program.--The term
`bridge or degree completion program' means a program of
education in professional nursing offered by an accredited
school of nursing, as defined in paragraph (2), that leads to
a baccalaureate degree in nursing. Such programs may include,
Registered Nurse (RN) to Bachelor's of Science of Nursing
(BSN) programs, RN to MSN (Master of Science of Nursing)
programs, or BSN to Doctoral programs.''.
Subtitle B--Innovations in the Health Care Workforce
SEC. 5101. NATIONAL HEALTH CARE WORKFORCE COMMISSION.
(a) Purpose.--It is the purpose of this section to
establish a National Health Care Workforce Commission that--
(1) serves as a national resource for Congress, the
President, States, and localities;
(2) communicates and coordinates with the Departments of
Health and Human Services, Labor, Veterans Affairs, Homeland
Security, and Education on related activities administered by
one or more of such Departments;
(3) develops and commissions evaluations of education and
training activities to determine whether the demand for
health care workers is being met;
(4) identifies barriers to improved coordination at the
Federal, State, and local levels and recommend ways to
address such barriers; and
(5) encourages innovations to address population needs,
constant changes in technology, and other environmental
factors.
(b) Establishment.--There is hereby established the
National Health Care Workforce Commission (in this section
referred to as the ``Commission'').
(c) Membership.--
(1) Number and appointment.--The Commission shall be
composed of 15 members to be appointed by the Comptroller
General, without regard to section 5 of the Federal Advisory
Committee Act (5 U.S.C. App.).
(2) Qualifications.--
(A) In general.--The membership of the Commission shall
include individuals--
(i) with national recognition for their expertise in health
care labor market analysis, including health care workforce
analysis; health care finance and economics; health care
facility management; health care plans and integrated
delivery systems; health care workforce education and
training; health care philanthropy; providers of health care
services; and other related fields; and
(ii) who will provide a combination of professional
perspectives, broad geographic representation, and a balance
between urban, suburban, rural, and frontier representatives.
(B) Inclusion.--
(i) In general.--The membership of the Commission shall
include no less than one representative of--
(I) the health care workforce and health professionals;
(II) employers;
(III) third-party payers;
(IV) individuals skilled in the conduct and interpretation
of health care services and health economics research;
(V) representatives of consumers;
(VI) labor unions;
(VII) State or local workforce investment boards; and
(VIII) educational institutions (which may include
elementary and secondary institutions, institutions of higher
education, including 2 and 4 year institutions, or registered
apprenticeship programs).
(ii) Additional members.--The remaining membership may
include additional representatives from clause (i) and other
individuals as determined appropriate by the Comptroller
General of the United States.
(C) Majority non-providers.--Individuals who are directly
involved in health professions education or practice shall
not constitute a majority of the membership of the
Commission.
(D) Ethical disclosure.--The Comptroller General shall
establish a system for public disclosure by members of the
Commission of financial and other potential conflicts of
interest relating to such members. Members of the Commission
shall be treated as employees of Congress for purposes of
applying title I of the Ethics in Government Act of 1978.
Members of the Commission shall not be treated as special
government employees under title 18, United States Code.
[[Page H2043]]
(3) Terms.--
(A) In general.--The terms of members of the Commission
shall be for 3 years except that the Comptroller General
shall designate staggered terms for the members first
appointed.
(B) Vacancies.--Any member appointed to fill a vacancy
occurring before the expiration of the term for which the
member's predecessor was appointed shall be appointed only
for the remainder of that term. A member may serve after the
expiration of that member's term until a successor has taken
office. A vacancy in the Commission shall be filled in the
manner in which the original appointment was made.
(C) Initial appointments.--The Comptroller General shall
make initial appointments of members to the Commission not
later than September 30, 2010.
(4) Compensation.--While serving on the business of the
Commission (including travel time), a member of the
Commission shall be entitled to compensation at the per diem
equivalent of the rate provided for level IV of the Executive
Schedule under section 5315 of tile 5, United States Code,
and while so serving away from home and the member's regular
place of business, a member may be allowed travel expenses,
as authorized by the Chairman of the Commission. Physicians
serving as personnel of the Commission may be provided a
physician comparability allowance by the Commission in the
same manner as Government physicians may be provided such an
allowance by an agency under section 5948 of title 5, United
States Code, and for such purpose subsection (i) of such
section shall apply to the Commission in the same manner as
it applies to the Tennessee Valley Authority. For purposes of
pay (other than pay of members of the Commission) and
employment benefits, rights, and privileges, all personnel of
the Commission shall be treated as if they were employees of
the United States Senate. Personnel of the Commission shall
not be treated as employees of the Government Accountability
Office for any purpose.
(5) Chairman, vice chairman.--The Comptroller General shall
designate a member of the Commission, at the time of
appointment of the member, as Chairman and a member as Vice
Chairman for that term of appointment, except that in the
case of vacancy of the chairmanship or vice chairmanship, the
Comptroller General may designate another member for the
remainder of that member's term.
(6) Meetings.--The Commission shall meet at the call of the
chairman, but no less frequently than on a quarterly basis.
(d) Duties.--
(1) Recognition, dissemination, and communication.--The
Commission shall--
(A) recognize efforts of Federal, State, and local
partnerships to develop and offer health care career pathways
of proven effectiveness;
(B) disseminate information on promising retention
practices for health care professionals; and
(C) communicate information on important policies and
practices that affect the recruitment, education and
training, and retention of the health care workforce.
(2) Review of health care workforce and annual reports.--In
order to develop a fiscally sustainable integrated workforce
that supports a high-quality, readily accessible health care
delivery system that meets the needs of patients and
populations, the Commission, in consultation with relevant
Federal, State, and local agencies, shall--
(A) review current and projected health care workforce
supply and demand, including the topics described in
paragraph (3);
(B) make recommendations to Congress and the Administration
concerning national health care workforce priorities, goals,
and policies;
(C) by not later than October 1 of each year (beginning
with 2011), submit a report to Congress and the
Administration containing the results of such reviews and
recommendations concerning related policies; and
(D) by not later than April 1 of each year (beginning with
2011), submit a report to Congress and the Administration
containing a review of, and recommendations on, at a minimum
one high priority area as described in paragraph (4).
(3) Specific topics to be reviewed.--The topics described
in this paragraph include--
(A) current health care workforce supply and distribution,
including demographics, skill sets, and demands, with
projected demands during the subsequent 10 and 25 year
periods;
(B) health care workforce education and training capacity,
including the number of students who have completed education
and training, including registered apprenticeships; the
number of qualified faculty; the education and training
infrastructure; and the education and training demands, with
projected demands during the subsequent 10 and 25 year
periods;
(C) the education loan and grant programs in titles VII and
VIII of the Public Health Service Act (42 U.S.C. 292 et seq.
and 296 et seq.), with recommendations on whether such
programs should become part of the Higher Education Act of
1965 (20 U.S.C. 1001 et seq);
(D) the implications of new and existing Federal policies
which affect the health care workforce, including Medicare
and Medicaid graduate medical education policies, titles VII
and VIII of the Public Health Service Act (42 U.S.C. 292 et
seq. and 296 et seq.), the National Health Service Corps
(with recommendations for aligning such programs with
national health workforce priorities and goals), and other
health care workforce programs, including those supported
through the Workforce Investment Act of 1998 (29 U.S.C. 2801
et seq.), the Carl D. Perkins Career and Technical Education
Act of 2006 (20 U.S.C. 2301 et seq.), the Higher Education
Act of 1965 (20 U.S.C. 1001 et seq.), and any other Federal
health care workforce programs;
(E) the health care workforce needs of special populations,
such as minorities, rural populations, medically underserved
populations, gender specific needs, individuals with
disabilities, and geriatric and pediatric populations with
recommendations for new and existing Federal policies to meet
the needs of these special populations; and
(F) recommendations creating or revising national loan
repayment programs and scholarship programs to require low-
income, minority medical students to serve in their home
communities, if designated as medical underserved community.
(4) High priority areas.--
(A) In general.--The initial high priority topics described
in this paragraph include each of the following:
(i) Integrated health care workforce planning that
identifies health care professional skills needed and
maximizes the skill sets of health care professionals across
disciplines.
(ii) An analysis of the nature, scopes of practice, and
demands for health care workers in the enhanced information
technology and management workplace.
(iii) An analysis of how to align Medicare and Medicaid
graduate medical education policies with national workforce
goals.
(iv) The education and training capacity, projected
demands, and integration with the health care delivery system
of each of the following:
(I) Nursing workforce capacity at all levels.
(II) Oral health care workforce capacity at all levels.
(III) Mental and behavioral health care workforce capacity
at all levels.
(IV) Allied health and public health care workforce
capacity at all levels.
(V) Emergency medical service workforce capacity, including
the retention and recruitment of the volunteer workforce, at
all levels.
(VI) The geographic distribution of health care providers
as compared to the identified health care workforce needs of
States and regions.
(B) Future determinations.--The Commission may require that
additional topics be included under subparagraph (A). The
appropriate committees of Congress may recommend to the
Commission the inclusion of other topics for health care
workforce development areas that require special attention.
(5) Grant program.--The Commission shall--
(A) review implementation progress reports on, and report
to Congress about, the State Health Care Workforce
Development Grant program established in section 5102;
(B) in collaboration with the Department of Labor and in
coordination with the Department of Education and other
relevant Federal agencies, make recommendations to the fiscal
and administrative agent under section 5102(b) for grant
recipients under section 5102;
(C) assess the implementation of the grants under such
section; and
(D) collect performance and report information, including
identified models and best practices, on grants from the
fiscal and administrative agent under such section and
distribute this information to Congress, relevant Federal
agencies, and to the public.
(6) Study.--The Commission shall study effective mechanisms
for financing education and training for careers in health
care, including public health and allied health.
(7) Recommendations.--The Commission shall submit
recommendations to Congress, the Department of Labor, and the
Department of Health and Human Services about improving
safety, health, and worker protections in the workplace for
the health care workforce.
(8) Assessment.--The Commission shall assess and receive
reports from the National Center for Health Care Workforce
Analysis established under section 761(b) of the Public
Service Health Act (as amended by section 5103).
(e) Consultation With Federal, State, and Local Agencies,
Congress, and Other Organizations.--
(1) In general.--The Commission shall consult with Federal
agencies (including the Departments of Health and Human
Services, Labor, Education, Commerce, Agriculture, Defense,
and Veterans Affairs and the Environmental Protection
Agency), Congress, the Medicare Payment Advisory Commission,
the Medicaid and CHIP Payment and Access Commission, and, to
the extent practicable, with State and local agencies, Indian
tribes, voluntary health care organizations, professional
societies, and other relevant public-private health care
partnerships.
(2) Obtaining official data.--The Commission, consistent
with established privacy rules, may secure directly from any
department or agency of the Executive Branch information
necessary to enable the Commission to carry out this section.
(3) Detail of federal government employees.--An employee of
the Federal Government may be detailed to the Commission
without reimbursement. The detail of such an employee shall
be without interruption or loss of civil service status.
(f) Director and Staff; Experts and Consultants.--Subject
to such review as the Comptroller General of the United
States determines to be necessary to ensure the efficient
administration of the Commission, the Commission may--
(1) employ and fix the compensation of an executive
director that shall not exceed the rate of basic pay payable
for level V of the Executive Schedule and such other
personnel as may be necessary to carry out its duties
(without regard to the provisions of title 5, United States
Code, governing appointments in the competitive service);
(2) seek such assistance and support as may be required in
the performance of its duties from appropriate Federal
departments and agencies;
(3) enter into contracts or make other arrangements, as may
be necessary for the conduct of the work of the Commission
(without regard to section 3709 of the Revised Statutes (41
U.S.C. 5));
[[Page H2044]]
(4) make advance, progress, and other payments which relate
to the work of the Commission;
(5) provide transportation and subsistence for persons
serving without compensation; and
(6) prescribe such rules and regulations as the Commission
determines to be necessary with respect to the internal
organization and operation of the Commission.
(g) Powers.--
(1) Data collection.--In order to carry out its functions
under this section, the Commission shall--
(A) utilize existing information, both published and
unpublished, where possible, collected and assessed either by
its own staff or under other arrangements made in accordance
with this section, including coordination with the Bureau of
Labor Statistics;
(B) carry out, or award grants or contracts for the
carrying out of, original research and development, where
existing information is inadequate, and
(C) adopt procedures allowing interested parties to submit
information for the Commission's use in making reports and
recommendations.
(2) Access of the government accountability office to
information.--The Comptroller General of the United States
shall have unrestricted access to all deliberations, records,
and data of the Commission, immediately upon request.
(3) Periodic audit.--The Commission shall be subject to
periodic audit by an independent public accountant under
contract to the Commission.
(h) Authorization of Appropriations.--
(1) Request for appropriations.--The Commission shall
submit requests for appropriations in the same manner as the
Comptroller General of the United States submits requests for
appropriations. Amounts so appropriated for the Commission
shall be separate from amounts appropriated for the
Comptroller General.
(2) Authorization.--There are authorized to be appropriated
such sums as may be necessary to carry out this section.
(3) Gifts and services.--The Commission may not accept
gifts, bequeaths, or donations of property, but may accept
and use donations of services for purposes of carrying out
this section.
(i) Definitions.--In this section:
(1) Health care workforce.--The term ``health care
workforce'' includes all health care providers with direct
patient care and support responsibilities, such as
physicians, nurses, nurse practitioners, primary care
providers, preventive medicine physicians, optometrists,
ophthalmologists, physician assistants, pharmacists,
dentists, dental hygienists, and other oral healthcare
professionals, allied health professionals, doctors of
chiropractic, community health workers, health care
paraprofessionals, direct care workers, psychologists and
other behavioral and mental health professionals (including
substance abuse prevention and treatment providers), social
workers, physical and occupational therapists, certified
nurse midwives, podiatrists, the EMS workforce (including
professional and volunteer ambulance personnel and
firefighters who perform emergency medical services),
licensed complementary and alternative medicine providers,
integrative health practitioners, public health
professionals, and any other health professional that the
Comptroller General of the United States determines
appropriate.
(2) Health professionals.--The term ``health
professionals'' includes--
(A) dentists, dental hygienists, primary care providers,
specialty physicians, nurses, nurse practitioners, physician
assistants, psychologists and other behavioral and mental
health professionals (including substance abuse prevention
and treatment providers), social workers, physical and
occupational therapists, public health professionals,
clinical pharmacists, allied health professionals, doctors of
chiropractic, community health workers, school nurses,
certified nurse midwives, podiatrists, licensed complementary
and alternative medicine providers, the EMS workforce
(including professional and volunteer ambulance personnel and
firefighters who perform emergency medical services), and
integrative health practitioners;
(B) national representatives of health professionals;
(C) representatives of schools of medicine, osteopathy,
nursing, dentistry, optometry, pharmacy, chiropractic, allied
health, educational programs for public health professionals,
behavioral and mental health professionals (as so defined),
social workers, pharmacists, physical and occupational
therapists, oral health care industry dentistry and dental
hygiene, and physician assistants;
(D) representatives of public and private teaching
hospitals, and ambulatory health facilities, including
Federal medical facilities; and
(E) any other health professional the Comptroller General
of the United States determines appropriate.
SEC. 5102. STATE HEALTH CARE WORKFORCE DEVELOPMENT GRANTS.
(a) Establishment.--There is established a competitive
health care workforce development grant program (referred to
in this section as the ``program'') for the purpose of
enabling State partnerships to complete comprehensive
planning and to carry out activities leading to coherent and
comprehensive health care workforce development strategies at
the State and local levels.
(b) Fiscal and Administrative Agent.--The Health Resources
and Services Administration of the Department of Health and
Human Services (referred to in this section as the
``Administration'') shall be the fiscal and administrative
agent for the grants awarded under this section. The
Administration is authorized to carry out the program, in
consultation with the National Health Care Workforce
Commission (referred to in this section as the
``Commission''), which shall review reports on the
development, implementation, and evaluation activities of the
grant program, including--
(1) administering the grants;
(2) providing technical assistance to grantees; and
(3) reporting performance information to the Commission.
(c) Planning Grants.--
(1) Amount and duration.--A planning grant shall be awarded
under this subsection for a period of not more than one year
and the maximum award may not be more than $150,000.
(2) Eligibility.--To be eligible to receive a planning
grant, an entity shall be an eligible partnership. An
eligible partnership shall be a State workforce investment
board, if it includes or modifies the members to include at
least one representative from each of the following: health
care employer, labor organization, a public 2-year
institution of higher education, a public 4-year institution
of higher education, the recognized State federation of
labor, the State public secondary education agency, the State
P-16 or P-20 Council if such a council exists, and a
philanthropic organization that is actively engaged in
providing learning, mentoring, and work opportunities to
recruit, educate, and train individuals for, and retain
individuals in, careers in health care and related
industries.
(3) Fiscal and administrative agent.--The Governor of the
State receiving a planning grant has the authority to appoint
a fiscal and an administrative agency for the partnership.
(4) Application.--Each State partnership desiring a
planning grant shall submit an application to the
Administrator of the Administration at such time and in such
manner, and accompanied by such information as the
Administrator may reasonable require. Each application
submitted for a planning grant shall describe the members of
the State partnership, the activities for which assistance is
sought, the proposed performance benchmarks to be used to
measure progress under the planning grant, a budget for use
of the funds to complete the required activities described in
paragraph (5), and such additional assurance and information
as the Administrator determines to be essential to ensure
compliance with the grant program requirements.
(5) Required activities.--A State partnership receiving a
planning grant shall carry out the following:
(A) Analyze State labor market information in order to
create health care career pathways for students and adults,
including dislocated workers.
(B) Identify current and projected high demand State or
regional health care sectors for purposes of planning career
pathways.
(C) Identify existing Federal, State, and private resources
to recruit, educate or train, and retain a skilled health
care workforce and strengthen partnerships.
(D) Describe the academic and health care industry skill
standards for high school graduation, for entry into
postsecondary education, and for various credentials and
licensure.
(E) Describe State secondary and postsecondary education
and training policies, models, or practices for the health
care sector, including career information and guidance
counseling.
(F) Identify Federal or State policies or rules to
developing a coherent and comprehensive health care workforce
development strategy and barriers and a plan to resolve these
barriers.
(G) Participate in the Administration's evaluation and
reporting activities.
(6) Performance and evaluation.--Before the State
partnership receives a planning grant, such partnership and
the Administrator of the Administration shall jointly
determine the performance benchmarks that will be established
for the purposes of the planning grant.
(7) Match.--Each State partnership receiving a planning
grant shall provide an amount, in cash or in kind, that is
not less that 15 percent of the amount of the grant, to carry
out the activities supported by the grant. The matching
requirement may be provided from funds available under other
Federal, State, local or private sources to carry out the
activities.
(8) Report.--
(A) Report to administration.--Not later than 1 year after
a State partnership receives a planning grant, the
partnership shall submit a report to the Administration on
the State's performance of the activities under the grant,
including the use of funds, including matching funds, to
carry out required activities, and a description of the
progress of the State workforce investment board in meeting
the performance benchmarks.
(B) Report to congress.--The Administration shall submit a
report to Congress analyzing the planning activities,
performance, and fund utilization of each State grant
recipient, including an identification of promising practices
and a profile of the activities of each State grant
recipient.
(d) Implementation Grants.--
(1) In general.--The Administration shall--
(A) competitively award implementation grants to State
partnerships to enable such partnerships to implement
activities that will result in a coherent and comprehensive
plan for health workforce development that will address
current and projected workforce demands within the State; and
(B) inform the Commission and Congress about the awards
made.
(2) Duration.--An implementation grant shall be awarded for
a period of no more than 2 years, except in those cases where
the Administration determines that the grantee is high
performing and the activities supported by the grant warrant
up to 1 additional year of funding.
(3) Eligibility.--To be eligible for an implementation
grant, a State partnership shall have--
[[Page H2045]]
(A) received a planning grant under subsection (c) and
completed all requirements of such grant; or
(B) completed a satisfactory application, including a plan
to coordinate with required partners and complete the
required activities during the 2 year period of the
implementation grant.
(4) Fiscal and administrative agent.--A State partnership
receiving an implementation grant shall appoint a fiscal and
an administration agent for the implementation of such grant.
(5) Application.--Each eligible State partnership desiring
an implementation grant shall submit an application to the
Administration at such time, in such manner, and accompanied
by such information as the Administration may reasonably
require. Each application submitted shall include--
(A) a description of the members of the State partnership;
(B) a description of how the State partnership completed
the required activities under the planning grant, if
applicable;
(C) a description of the activities for which
implementation grant funds are sought, including grants to
regions by the State partnership to advance coherent and
comprehensive regional health care workforce planning
activities;
(D) a description of how the State partnership will
coordinate with required partners and complete the required
partnership activities during the duration of an
implementation grant;
(E) a budget proposal of the cost of the activities
supported by the implementation grant and a timeline for the
provision of matching funds required;
(F) proposed performance benchmarks to be used to assess
and evaluate the progress of the partnership activities;
(G) a description of how the State partnership will collect
data to report progress in grant activities; and
(H) such additional assurances as the Administration
determines to be essential to ensure compliance with grant
requirements.
(6) Required activities.--
(A) In general.--A State partnership that receives an
implementation grant may reserve not less than 60 percent of
the grant funds to make grants to be competitively awarded by
the State partnership, consistent with State procurement
rules, to encourage regional partnerships to address health
care workforce development needs and to promote innovative
health care workforce career pathway activities, including
career counseling, learning, and employment.
(B) Eligible partnership duties.--An eligible State
partnership receiving an implementation grant shall--
(i) identify and convene regional leadership to discuss
opportunities to engage in statewide health care workforce
development planning, including the potential use of
competitive grants to improve the development, distribution,
and diversity of the regional health care workforce; the
alignment of curricula for health care careers; and the
access to quality career information and guidance and
education and training opportunities;
(ii) in consultation with key stakeholders and regional
leaders, take appropriate steps to reduce Federal, State, or
local barriers to a comprehensive and coherent strategy,
including changes in State or local policies to foster
coherent and comprehensive health care workforce development
activities, including health care career pathways at the
regional and State levels, career planning information,
retraining for dislocated workers, and as appropriate,
requests for Federal program or administrative waivers;
(iii) develop, disseminate, and review with key
stakeholders a preliminary statewide strategy that addresses
short- and long-term health care workforce development supply
versus demand;
(iv) convene State partnership members on a regular basis,
and at least on a semiannual basis;
(v) assist leaders at the regional level to form
partnerships, including technical assistance and capacity
building activities;
(vi) collect and assess data on and report on the
performance benchmarks selected by the State partnership and
the Administration for implementation activities carried out
by regional and State partnerships; and
(vii) participate in the Administration's evaluation and
reporting activities.
(7) Performance and evaluation.--Before the State
partnership receives an implementation grant, it and the
Administrator shall jointly determine the performance
benchmarks that shall be established for the purposes of the
implementation grant.
(8) Match.--Each State partnership receiving an
implementation grant shall provide an amount, in cash or in
kind that is not less than 25 percent of the amount of the
grant, to carry out the activities supported by the grant.
The matching funds may be provided from funds available from
other Federal, State, local, or private sources to carry out
such activities.
(9) Reports.--
(A) Report to administration.--For each year of the
implementation grant, the State partnership receiving the
implementation grant shall submit a report to the
Administration on the performance of the State of the grant
activities, including a description of the use of the funds,
including matched funds, to complete activities, and a
description of the performance of the State partnership in
meeting the performance benchmarks.
(B) Report to congress.--The Administration shall submit a
report to Congress analyzing implementation activities,
performance, and fund utilization of the State grantees,
including an identification of promising practices and a
profile of the activities of each State grantee.
(e) Authorization for Appropriations.--
(1) Planning grants.--There are authorized to be
appropriated to award planning grants under subsection (c)
$8,000,000 for fiscal year 2010, and such sums as may be
necessary for each subsequent fiscal year.
(2) Implementation grants.--There are authorized to be
appropriated to award implementation grants under subsection
(d), $150,000,000 for fiscal year 2010, and such sums as may
be necessary for each subsequent fiscal year.
SEC. 5103. HEALTH CARE WORKFORCE ASSESSMENT.
(a) In General.--Section 761 of the Public Health Service
Act (42 U.S.C. 294m) is amended--
(1) by redesignating subsection (c) as subsection (e);
(2) by striking subsection (b) and inserting the following:
``(b) National Center for Health Care Workforce Analysis.--
``(1) Establishment.--The Secretary shall establish the
National Center for Health Workforce Analysis (referred to in
this section as the `National Center').
``(2) Purposes.--The National Center, in coordination to
the extent practicable with the National Health Care
Workforce Commission (established in section 5101 of the
Patient Protection and Affordable Care Act), and relevant
regional and State centers and agencies, shall--
``(A) provide for the development of information describing
and analyzing the health care workforce and workforce related
issues;
``(B) carry out the activities under section 792(a);
``(C) annually evaluate programs under this title;
``(D) develop and publish performance measures and
benchmarks for programs under this title; and
``(E) establish, maintain, and publicize a national
Internet registry of each grant awarded under this title and
a database to collect data from longitudinal evaluations (as
described in subsection (d)(2)) on performance measures (as
developed under sections 749(d)(3), 757(d)(3), and
762(a)(3)).
``(3) Collaboration and data sharing.--
``(A) In general.--The National Center shall collaborate
with Federal agencies and relevant professional and
educational organizations or societies for the purpose of
linking data regarding grants awarded under this title.
``(B) Contracts for health workforce analysis.--For the
purpose of carrying out the activities described in
subparagraph (A), the National Center may enter into
contracts with relevant professional and educational
organizations or societies.
``(c) State and Regional Centers for Health Workforce
Analysis.--
``(1) In general.--The Secretary shall award grants to, or
enter into contracts with, eligible entities for purposes
of--
``(A) collecting, analyzing, and reporting data regarding
programs under this title to the National Center and to the
public; and
``(B) providing technical assistance to local and regional
entities on the collection, analysis, and reporting of data.
``(2) Eligible entities.--To be eligible for a grant or
contract under this subsection, an entity shall--
``(A) be a State, a State workforce investment board, a
public health or health professions school, an academic
health center, or an appropriate public or private nonprofit
entity; and
``(B) submit to the Secretary an application at such time,
in such manner, and containing such information as the
Secretary may require.
``(d) Increase in Grants for Longitudinal Evaluations.--
``(1) In general.--The Secretary shall increase the amount
awarded to an eligible entity under this title for a
longitudinal evaluation of individuals who have received
education, training, or financial assistance from programs
under this title.
``(2) Capability.--A longitudinal evaluation shall be
capable of--
``(A) studying practice patterns; and
``(B) collecting and reporting data on performance measures
developed under sections 749(d)(3), 757(d)(3), and 762(a)(3).
``(3) Guidelines.--A longitudinal evaluation shall comply
with guidelines issued under sections 749(d)(4), 757(d)(4),
and 762(a)(4).
``(4) Eligible entities.--To be eligible to obtain an
increase under this section, an entity shall be a recipient
of a grant or contract under this title.''; and
(3) in subsection (e), as so redesignated--
(A) by striking paragraph (1) and inserting the following:
``(1) In general.--
``(A) National center.--To carry out subsection (b), there
are authorized to be appropriated $7,500,000 for each of
fiscal years 2010 through 2014.
``(B) State and regional centers.--To carry out subsection
(c), there are authorized to be appropriated $4,500,000 for
each of fiscal years 2010 through 2014.
``(C) Grants for longitudinal evaluations.--To carry out
subsection (d), there are authorized to be appropriated such
sums as may be necessary for fiscal years 2010 through
2014.''; and
(4) in paragraph (2), by striking ``subsection (a)'' and
inserting ``paragraph (1)''.
(b) Transfers.--Not later than 180 days after the date of
enactment of this Act, the responsibilities and resources of
the National Center for Health Workforce Analysis, as in
effect on the date before the date of enactment of this Act,
shall be transferred to the National Center for Health Care
Workforce Analysis established under section 761 of the
Public Health Service Act, as amended by subsection (a).
(c) Use of Longitudinal Evaluations.--Section 791(a)(1) of
the Public Health Service Act (42 U.S.C. 295j(a)(1)) is
amended--
(1) in subparagraph (A), by striking ``or'' at the end;
(2) in subparagraph (B), by striking the period and
inserting ``; or''; and
[[Page H2046]]
(3) by adding at the end the following:
``(C) utilizes a longitudinal evaluation (as described in
section 761(d)(2)) and reports data from such system to the
national workforce database (as established under section
761(b)(2)(E)).''.
(d) Performance Measures; Guidelines for Longitudinal
Evaluations.--
(1) Advisory committee on training in primary care medicine
and dentistry.--Section 748(d) of the Public Health Service
Act is amended--
(A) in paragraph (1), by striking ``and'' at the end;
(B) in paragraph (2), by striking the period and inserting
a semicolon; and
(C) by adding at the end the following:
``(3) develop, publish, and implement performance measures
for programs under this part;
``(4) develop and publish guidelines for longitudinal
evaluations (as described in section 761(d)(2)) for programs
under this part; and
``(5) recommend appropriation levels for programs under
this part.''.
(2) Advisory committee on interdisciplinary, community-
based linkages.--Section 756(d) of the Public Health Service
Act is amended--
(A) in paragraph (1), by striking ``and'' at the end;
(B) in paragraph (2), by striking the period and inserting
a semicolon; and
(C) by adding at the end the following:
``(3) develop, publish, and implement performance measures
for programs under this part;
``(4) develop and publish guidelines for longitudinal
evaluations (as described in section 761(d)(2)) for programs
under this part; and
``(5) recommend appropriation levels for programs under
this part.''.
(3) Advisory council on graduate medical education.--
Section 762(a) of the Public Health Service Act (42 U.S.C.
294o(a)) is amended--
(A) in paragraph (1), by striking ``and'' at the end;
(B) in paragraph (2), by striking the period and inserting
a semicolon; and
(C) by adding at the end the following:
``(3) develop, publish, and implement performance measures
for programs under this title, except for programs under part
C or D;
``(4) develop and publish guidelines for longitudinal
evaluations (as described in section 761(d)(2)) for programs
under this title, except for programs under part C or D; and
``(5) recommend appropriation levels for programs under
this title, except for programs under part C or D.''.
Subtitle C--Increasing the Supply of the Health Care Workforce
SEC. 5201. FEDERALLY SUPPORTED STUDENT LOAN FUNDS.
(a) Medical Schools and Primary Health Care.--Section 723
of the Public Health Service Act (42 U.S.C. 292s) is
amended--
(1) in subsection (a)--
(A) in paragraph (1), by striking subparagraph (B) and
inserting the following:
``(B) to practice in such care for 10 years (including
residency training in primary health care) or through the
date on which the loan is repaid in full, whichever occurs
first.''; and
(B) by striking paragraph (3) and inserting the following:
``(3) Noncompliance by student.--Each agreement entered
into with a student pursuant to paragraph (1) shall provide
that, if the student fails to comply with such agreement, the
loan involved will begin to accrue interest at a rate of 2
percent per year greater than the rate at which the student
would pay if compliant in such year.''; and
(2) by adding at the end the following:
``(d) Sense of Congress.--It is the sense of Congress that
funds repaid under the loan program under this section should
not be transferred to the Treasury of the United States or
otherwise used for any other purpose other than to carry out
this section.''.
(b) Student Loan Guidelines.--The Secretary of Health and
Human Services shall not require parental financial
information for an independent student to determine financial
need under section 723 of the Public Health Service Act (42
U.S.C. 292s) and the determination of need for such
information shall be at the discretion of applicable school
loan officer. The Secretary shall amend guidelines issued by
the Health Resources and Services Administration in
accordance with the preceding sentence.
SEC. 5202. NURSING STUDENT LOAN PROGRAM.
(a) Loan Agreements.--Section 836(a) of the Public Health
Service Act (42 U.S.C. 297b(a)) is amended--
(1) by striking ``$2,500'' and inserting ``$3,300'';
(2) by striking ``$4,000'' and inserting ``$5,200''; and
(3) by striking ``$13,000'' and all that follows through
the period and inserting ``$17,000 in the case of any student
during fiscal years 2010 and 2011. After fiscal year 2011,
such amounts shall be adjusted to provide for a cost-of-
attendance increase for the yearly loan rate and the
aggregate of the loans.''.
(b) Loan Provisions.--Section 836(b) of the Public Health
Service Act (42 U.S.C. 297b(b)) is amended--
(1) in paragraph (1)(C), by striking ``1986'' and inserting
``2000''; and
(2) in paragraph (3), by striking ``the date of enactment
of the Nurse Training Amendments of 1979'' and inserting
``September 29, 1995''.
SEC. 5203. HEALTH CARE WORKFORCE LOAN REPAYMENT PROGRAMS.
Part E of title VII of the Public Health Service Act (42
U.S.C. 294n et seq.) is amended by adding at the end the
following:
``Subpart 3--Recruitment and Retention Programs
``SEC. 775. INVESTMENT IN TOMORROW'S PEDIATRIC HEALTH CARE
WORKFORCE.
``(a) Establishment.--The Secretary shall establish and
carry out a pediatric specialty loan repayment program under
which the eligible individual agrees to be employed full-time
for a specified period (which shall not be less than 2 years)
in providing pediatric medical subspecialty, pediatric
surgical specialty, or child and adolescent mental and
behavioral health care, including substance abuse prevention
and treatment services.
``(b) Program Administration.--Through the program
established under this section, the Secretary shall enter
into contracts with qualified health professionals under
which--
``(1) such qualified health professionals will agree to
provide pediatric medical subspecialty, pediatric surgical
specialty, or child and adolescent mental and behavioral
health care in an area with a shortage of the specified
pediatric subspecialty that has a sufficient pediatric
population to support such pediatric subspecialty, as
determined by the Secretary; and
``(2) the Secretary agrees to make payments on the
principal and interest of undergraduate, graduate, or
graduate medical education loans of professionals described
in paragraph (1) of not more than $35,000 a year for each
year of agreed upon service under such paragraph for a period
of not more than 3 years during the qualified health
professional's--
``(A) participation in an accredited pediatric medical
subspecialty, pediatric surgical specialty, or child and
adolescent mental health subspecialty residency or
fellowship; or
``(B) employment as a pediatric medical subspecialist,
pediatric surgical specialist, or child and adolescent mental
health professional serving an area or population described
in such paragraph.
``(c) In General.--
``(1) Eligible individuals.--
``(A) Pediatric medical specialists and pediatric surgical
specialists.--For purposes of contracts with respect to
pediatric medical specialists and pediatric surgical
specialists, the term `qualified health professional' means a
licensed physician who--
``(i) is entering or receiving training in an accredited
pediatric medical subspecialty or pediatric surgical
specialty residency or fellowship; or
``(ii) has completed (but not prior to the end of the
calendar year in which this section is enacted) the training
described in subparagraph (B).
``(B) Child and adolescent mental and behavioral health.--
For purposes of contracts with respect to child and
adolescent mental and behavioral health care, the term
`qualified health professional' means a health care
professional who--
``(i) has received specialized training or clinical
experience in child and adolescent mental health in
psychiatry, psychology, school psychology, behavioral
pediatrics, psychiatric nursing, social work, school social
work, substance abuse disorder prevention and treatment,
marriage and family therapy, school counseling, or
professional counseling;
``(ii) has a license or certification in a State to
practice allopathic medicine, osteopathic medicine,
psychology, school psychology, psychiatric nursing, social
work, school social work, marriage and family therapy, school
counseling, or professional counseling; or
``(iii) is a mental health service professional who
completed (but not before the end of the calendar year in
which this section is enacted) specialized training or
clinical experience in child and adolescent mental health
described in clause (i).
``(2) Additional eligibility requirements.--The Secretary
may not enter into a contract under this subsection with an
eligible individual unless--
``(A) the individual agrees to work in, or for a provider
serving, a health professional shortage area or medically
underserved area, or to serve a medically underserved
population;
``(B) the individual is a United States citizen or a
permanent legal United States resident; and
``(C) if the individual is enrolled in a graduate program,
the program is accredited, and the individual has an
acceptable level of academic standing (as determined by the
Secretary).
``(d) Priority.--In entering into contracts under this
subsection, the Secretary shall give priority to applicants
who--
``(1) are or will be working in a school or other pre-
kindergarten, elementary, or secondary education setting;
``(2) have familiarity with evidence-based methods and
cultural and linguistic competence health care services; and
``(3) demonstrate financial need.
``(e) Authorization of Appropriations.--There is authorized
to be appropriated $30,000,000 for each of fiscal years 2010
through 2014 to carry out subsection (c)(1)(A) and
$20,000,000 for each of fiscal years 2010 through 2013 to
carry out subsection (c)(1)(B).''.
SEC. 5204. PUBLIC HEALTH WORKFORCE RECRUITMENT AND RETENTION
PROGRAMS.
Part E of title VII of the Public Health Service Act (42
U.S.C. 294n et seq.), as amended by section 5203, is further
amended by adding at the end the following:
``SEC. 776. PUBLIC HEALTH WORKFORCE LOAN REPAYMENT PROGRAM.
``(a) Establishment.--The Secretary shall establish the
Public Health Workforce Loan Repayment Program (referred to
in this section as the `Program') to assure an adequate
supply of public health professionals to eliminate critical
public health workforce shortages in Federal, State, local,
and tribal public health agencies.
``(b) Eligibility.--To be eligible to participate in the
Program, an individual shall--
``(1)(A) be accepted for enrollment, or be enrolled, as a
student in an accredited academic
[[Page H2047]]
educational institution in a State or territory in the final
year of a course of study or program leading to a public
health or health professions degree or certificate; and have
accepted employment with a Federal, State, local, or tribal
public health agency, or a related training fellowship, as
recognized by the Secretary, to commence upon graduation;
``(B)(i) have graduated, during the preceding 10-year
period, from an accredited educational institution in a State
or territory and received a public health or health
professions degree or certificate; and
``(ii) be employed by, or have accepted employment with, a
Federal, State, local, or tribal public health agency or a
related training fellowship, as recognized by the Secretary;
``(2) be a United States citizen; and
``(3)(A) submit an application to the Secretary to
participate in the Program;
``(B) execute a written contract as required in subsection
(c); and
``(4) not have received, for the same service, a reduction
of loan obligations under section 455(m), 428J, 428K, 428L,
or 460 of the Higher Education Act of 1965.
``(c) Contract.--The written contract (referred to in this
section as the `written contract') between the Secretary and
an individual shall contain--
``(1) an agreement on the part of the Secretary that the
Secretary will repay on behalf of the individual loans
incurred by the individual in the pursuit of the relevant
degree or certificate in accordance with the terms of the
contract;
``(2) an agreement on the part of the individual that the
individual will serve in the full-time employment of a
Federal, State, local, or tribal public health agency or a
related fellowship program in a position related to the
course of study or program for which the contract was awarded
for a period of time (referred to in this section as the
`period of obligated service') equal to the greater of--
``(A) 3 years; or
``(B) such longer period of time as determined appropriate
by the Secretary and the individual;
``(3) an agreement, as appropriate, on the part of the
individual to relocate to a priority service area (as
determined by the Secretary) in exchange for an additional
loan repayment incentive amount to be determined by the
Secretary;
``(4) a provision that any financial obligation of the
United States arising out of a contract entered into under
this section and any obligation of the individual that is
conditioned thereon, is contingent on funds being
appropriated for loan repayments under this section;
``(5) a statement of the damages to which the United States
is entitled, under this section for the individual's breach
of the contract; and
``(6) such other statements of the rights and liabilities
of the Secretary and of the individual, not inconsistent with
this section.
``(d) Payments.--
``(1) In general.--A loan repayment provided for an
individual under a written contract under the Program shall
consist of payment, in accordance with paragraph (2), on
behalf of the individual of the principal, interest, and
related expenses on government and commercial loans received
by the individual regarding the undergraduate or graduate
education of the individual (or both), which loans were made
for tuition expenses incurred by the individual.
``(2) Payments for years served.--For each year of
obligated service that an individual contracts to serve under
subsection (c) the Secretary may pay up to $35,000 on behalf
of the individual for loans described in paragraph (1). With
respect to participants under the Program whose total
eligible loans are less than $105,000, the Secretary shall
pay an amount that does not exceed \1/3\ of the eligible loan
balance for each year of obligated service of the individual.
``(3) Tax liability.--For the purpose of providing
reimbursements for tax liability resulting from payments
under paragraph (2) on behalf of an individual, the Secretary
shall, in addition to such payments, make payments to the
individual in an amount not to exceed 39 percent of the total
amount of loan repayments made for the taxable year involved.
``(e) Postponing Obligated Service.--With respect to an
individual receiving a degree or certificate from a health
professions or other related school, the date of the
initiation of the period of obligated service may be
postponed as approved by the Secretary.
``(f) Breach of Contract.--An individual who fails to
comply with the contract entered into under subsection (c)
shall be subject to the same financial penalties as provided
for under section 338E for breaches of loan repayment
contracts under section 338B.
``(g) Authorization of Appropriations.--There is authorized
to be appropriated to carry out this section $195,000,000 for
fiscal year 2010, and such sums as may be necessary for each
of fiscal years 2011 through 2015.''.
SEC. 5205. ALLIED HEALTH WORKFORCE RECRUITMENT AND RETENTION
PROGRAMS.
(a) Purpose.--The purpose of this section is to assure an
adequate supply of allied health professionals to eliminate
critical allied health workforce shortages in Federal, State,
local, and tribal public health agencies or in settings where
patients might require health care services, including acute
care facilities, ambulatory care facilities, personal
residences and other settings, as recognized by the Secretary
of Health and Human Services by authorizing an Allied Health
Loan Forgiveness Program.
(b) Allied Health Workforce Recruitment and Retention
Program.--Section 428K of the Higher Education Act of 1965
(20 U.S.C. 1078-11) is amended--
(1) in subsection (b), by adding at the end the following:
``(18) Allied health professionals.--The individual is
employed full-time as an allied health professional--
``(A) in a Federal, State, local, or tribal public health
agency; or
``(B) in a setting where patients might require health care
services, including acute care facilities, ambulatory care
facilities, personal residences and other settings located in
health professional shortage areas, medically underserved
areas, or medically underserved populations, as recognized by
the Secretary of Health and Human Services.''; and
(2) in subsection (g)--
(A) by redesignating paragraphs (1) through (9) as
paragraphs (2) through (10), respectively; and
(B) by inserting before paragraph (2) (as redesignated by
subparagraph (A)) the following:
``(1) Allied health professional.--The term `allied health
professional' means an allied health professional as defined
in section 799B(5) of the Public Heath Service Act (42 U.S.C.
295p(5)) who--
``(A) has graduated and received an allied health
professions degree or certificate from an institution of
higher education; and
``(B) is employed with a Federal, State, local or tribal
public health agency, or in a setting where patients might
require health care services, including acute care
facilities, ambulatory care facilities, personal residences
and other settings located in health professional shortage
areas, medically underserved areas, or medically underserved
populations, as recognized by the Secretary of Health and
Human Services.''.
SEC. 5206. GRANTS FOR STATE AND LOCAL PROGRAMS.
(a) In General.--Section 765(d) of the Public Health
Service Act (42 U.S.C. 295(d)) is amended--
(1) in paragraph (7), by striking ``; or'' and inserting a
semicolon;
(2) by redesignating paragraph (8) as paragraph (9); and
(3) by inserting after paragraph (7) the following:
``(8) public health workforce loan repayment programs;
or''.
(b) Training for Mid-career Public Health Professionals.--
Part E of title VII of the Public Health Service Act (42
U.S.C. 294n et seq.), as amended by section 5204, is further
amended by adding at the end the following:
``SEC. 777. TRAINING FOR MID-CAREER PUBLIC AND ALLIED HEALTH
PROFESSIONALS.
``(a) In General.--The Secretary may make grants to, or
enter into contracts with, any eligible entity to award
scholarships to eligible individuals to enroll in degree or
professional training programs for the purpose of enabling
mid-career professionals in the public health and allied
health workforce to receive additional training in the field
of public health and allied health.
``(b) Eligibility.--
``(1) Eligible entity.--The term `eligible entity'
indicates an accredited educational institution that offers a
course of study, certificate program, or professional
training program in public or allied health or a related
discipline, as determined by the Secretary
``(2) Eligible individuals.--The term `eligible
individuals' includes those individuals employed in public
and allied health positions at the Federal, State, tribal, or
local level who are interested in retaining or upgrading
their education.
``(c) Authorization of Appropriations.--There is authorized
to be appropriated to carry out this section, $60,000,000 for
fiscal year 2010 and such sums as may be necessary for each
of fiscal years 2011 through 2015. Fifty percent of
appropriated funds shall be allotted to public health mid-
career professionals and 50 percent shall be allotted to
allied health mid-career professionals.''.
SEC. 5207. FUNDING FOR NATIONAL HEALTH SERVICE CORPS.
Section 338H(a) of the Public Health Service Act (42 U.S.C.
254q(a)) is amended to read as follows:
``(a) Authorization of Appropriations.--For the purpose of
carrying out this section, there is authorized to be
appropriated, out of any funds in the Treasury not otherwise
appropriated, the following:
``(1) For fiscal year 2010, $320,461,632.
``(2) For fiscal year 2011, $414,095,394.
``(3) For fiscal year 2012, $535,087,442.
``(4) For fiscal year 2013, $691,431,432.
``(5) For fiscal year 2014, $893,456,433.
``(6) For fiscal year 2015, $1,154,510,336.
``(7) For fiscal year 2016, and each subsequent fiscal
year, the amount appropriated for the preceding fiscal year
adjusted by the product of--
``(A) one plus the average percentage increase in the costs
of health professions education during the prior fiscal year;
and
``(B) one plus the average percentage change in the number
of individuals residing in health professions shortage areas
designated under section 333 during the prior fiscal year,
relative to the number of individuals residing in such areas
during the previous fiscal year.''.
SEC. 5208. NURSE-MANAGED HEALTH CLINICS.
(a) Purpose.--The purpose of this section is to fund the
development and operation of nurse-managed health clinics.
(b) Grants.--Subpart 1 of part D of title III of the Public
Health Service Act (42 U.S.C. 254b et seq.) is amended by
inserting after section 330A the following:
``SEC. 330A-1. GRANTS TO NURSE-MANAGED HEALTH CLINICS.
``(a) Definitions.--
``(1) Comprehensive primary health care services.--In this
section, the term `comprehensive primary health care
services' means the primary health services described in
section 330(b)(1).
``(2) Nurse-managed health clinic.--The term `nurse-managed
health clinic' means a
[[Page H2048]]
nurse-practice arrangement, managed by advanced practice
nurses, that provides primary care or wellness services to
underserved or vulnerable populations and that is associated
with a school, college, university or department of nursing,
federally qualified health center, or independent nonprofit
health or social services agency.
``(b) Authority to Award Grants.--The Secretary shall award
grants for the cost of the operation of nurse-managed health
clinics that meet the requirements of this section.
``(c) Applications.--To be eligible to receive a grant
under this section, an entity shall--
``(1) be an NMHC; and
``(2) submit to the Secretary an application at such time,
in such manner, and containing--
``(A) assurances that nurses are the major providers of
services at the NMHC and that at least 1 advanced practice
nurse holds an executive management position within the
organizational structure of the NMHC;
``(B) an assurance that the NMHC will continue providing
comprehensive primary health care services or wellness
services without regard to income or insurance status of the
patient for the duration of the grant period; and
``(C) an assurance that, not later than 90 days of
receiving a grant under this section, the NMHC will establish
a community advisory committee, for which a majority of the
members shall be individuals who are served by the NMHC.
``(d) Grant Amount.--The amount of any grant made under
this section for any fiscal year shall be determined by the
Secretary, taking into account--
``(1) the financial need of the NMHC, considering State,
local, and other operational funding provided to the NMHC;
and
``(2) other factors, as the Secretary determines
appropriate.
``(e) Authorization of Appropriations.--For the purposes of
carrying out this section, there are authorized to be
appropriated $50,000,000 for the fiscal year 2010 and such
sums as may be necessary for each of the fiscal years 2011
through 2014.''.
SEC. 5209. ELIMINATION OF CAP ON COMMISSIONED CORPS.
Section 202 of the Department of Health and Human Services
Appropriations Act, 1993 (Public Law 102-394) is amended by
striking ``not to exceed 2,800''.
SEC. 5210. ESTABLISHING A READY RESERVE CORPS.
Section 203 of the Public Health Service Act (42 U.S.C.
204) is amended to read as follows:
``SEC. 203. COMMISSIONED CORPS AND READY RESERVE CORPS.
``(a) Establishment.--
``(1) In general.--There shall be in the Service a
commissioned Regular Corps and a Ready Reserve Corps for
service in time of national emergency.
``(2) Requirement.--All commissioned officers shall be
citizens of the United States and shall be appointed without
regard to the civil-service laws and compensated without
regard to the Classification Act of 1923, as amended.
``(3) Appointment.--Commissioned officers of the Ready
Reserve Corps shall be appointed by the President and
commissioned officers of the Regular Corps shall be appointed
by the President with the advice and consent of the Senate.
``(4) Active duty.--Commissioned officers of the Ready
Reserve Corps shall at all times be subject to call to active
duty by the Surgeon General, including active duty for the
purpose of training.
``(5) Warrant officers.--Warrant officers may be appointed
to the Service for the purpose of providing support to the
health and delivery systems maintained by the Service and any
warrant officer appointed to the Service shall be considered
for purposes of this Act and title 37, United States Code, to
be a commissioned officer within the Commissioned Corps of
the Service.
``(b) Assimilating Reserve Corp Officers Into the Regular
Corps.--Effective on the date of enactment of the Patient
Protection and Affordable Care Act, all individuals
classified as officers in the Reserve Corps under this
section (as such section existed on the day before the date
of enactment of such Act) and serving on active duty shall be
deemed to be commissioned officers of the Regular Corps.
``(c) Purpose and Use of Ready Research.--
``(1) Purpose.--The purpose of the Ready Reserve Corps is
to fulfill the need to have additional Commissioned Corps
personnel available on short notice (similar to the uniformed
service's reserve program) to assist regular Commissioned
Corps personnel to meet both routine public health and
emergency response missions.
``(2) Uses.--The Ready Reserve Corps shall--
``(A) participate in routine training to meet the general
and specific needs of the Commissioned Corps;
``(B) be available and ready for involuntary calls to
active duty during national emergencies and public health
crises, similar to the uniformed service reserve personnel;
``(C) be available for backfilling critical positions left
vacant during deployment of active duty Commissioned Corps
members, as well as for deployment to respond to public
health emergencies, both foreign and domestic; and
``(D) be available for service assignment in isolated,
hardship, and medically underserved communities (as defined
in section 799B) to improve access to health services.
``(d) Funding.--For the purpose of carrying out the duties
and responsibilities of the Commissioned Corps under this
section, there are authorized to be appropriated $5,000,000
for each of fiscal years 2010 through 2014 for recruitment
and training and $12,500,000 for each of fiscal years 2010
through 2014 for the Ready Reserve Corps.''.
Subtitle D--Enhancing Health Care Workforce Education and Training
SEC. 5301. TRAINING IN FAMILY MEDICINE, GENERAL INTERNAL
MEDICINE, GENERAL PEDIATRICS, AND PHYSICIAN
ASSISTANTSHIP.
Part C of title VII (42 U.S.C. 293k et seq.) is amended by
striking section 747 and inserting the following:
``SEC. 747. PRIMARY CARE TRAINING AND ENHANCEMENT.
``(a) Support and Development of Primary Care Training
Programs.--
``(1) In general.--The Secretary may make grants to, or
enter into contracts with, an accredited public or nonprofit
private hospital, school of medicine or osteopathic medicine,
academically affiliated physician assistant training program,
or a public or private nonprofit entity which the Secretary
has determined is capable of carrying out such grant or
contract--
``(A) to plan, develop, operate, or participate in an
accredited professional training program, including an
accredited residency or internship program in the field of
family medicine, general internal medicine, or general
pediatrics for medical students, interns, residents, or
practicing physicians as defined by the Secretary;
``(B) to provide need-based financial assistance in the
form of traineeships and fellowships to medical students,
interns, residents, practicing physicians, or other medical
personnel, who are participants in any such program, and who
plan to specialize or work in the practice of the fields
defined in subparagraph (A);
``(C) to plan, develop, and operate a program for the
training of physicians who plan to teach in family medicine,
general internal medicine, or general pediatrics training
programs;
``(D) to plan, develop, and operate a program for the
training of physicians teaching in community-based settings;
``(E) to provide financial assistance in the form of
traineeships and fellowships to physicians who are
participants in any such programs and who plan to teach or
conduct research in a family medicine, general internal
medicine, or general pediatrics training program;
``(F) to plan, develop, and operate a physician assistant
education program, and for the training of individuals who
will teach in programs to provide such training;
``(G) to plan, develop, and operate a demonstration program
that provides training in new competencies, as recommended by
the Advisory Committee on Training in Primary Care Medicine
and Dentistry and the National Health Care Workforce
Commission established in section 5101 of the Patient
Protection and Affordable Care Act, which may include--
``(i) providing training to primary care physicians
relevant to providing care through patient-centered medical
homes (as defined by the Secretary for purposes of this
section);
``(ii) developing tools and curricula relevant to patient-
centered medical homes; and
``(iii) providing continuing education to primary care
physicians relevant to patient-centered medical homes; and
``(H) to plan, develop, and operate joint degree programs
to provide interdisciplinary and interprofessional graduate
training in public health and other health professions to
provide training in environmental health, infectious disease
control, disease prevention and health promotion,
epidemiological studies and injury control.
``(2) Duration of awards.--The period during which payments
are made to an entity from an award of a grant or contract
under this subsection shall be 5 years.
``(b) Capacity Building in Primary Care.--
``(1) In general.--The Secretary may make grants to or
enter into contracts with accredited schools of medicine or
osteopathic medicine to establish, maintain, or improve--
``(A) academic units or programs that improve clinical
teaching and research in fields defined in subsection
(a)(1)(A); or
``(B) programs that integrate academic administrative units
in fields defined in subsection (a)(1)(A) to enhance
interdisciplinary recruitment, training, and faculty
development.
``(2) Preference in making awards under this subsection.--
In making awards of grants and contracts under paragraph (1),
the Secretary shall give preference to any qualified
applicant for such an award that agrees to expend the award
for the purpose of--
``(A) establishing academic units or programs in fields
defined in subsection (a)(1)(A); or
``(B) substantially expanding such units or programs.
``(3) Priorities in making awards.--In awarding grants or
contracts under paragraph (1), the Secretary shall give
priority to qualified applicants that--
``(A) proposes a collaborative project between academic
administrative units of primary care;
``(B) proposes innovative approaches to clinical teaching
using models of primary care, such as the patient centered
medical home, team management of chronic disease, and
interprofessional integrated models of health care that
incorporate transitions in health care settings and
integration physical and mental health provision;
``(C) have a record of training the greatest percentage of
providers, or that have demonstrated significant improvements
in the percentage of providers trained, who enter and remain
in primary care practice;
``(D) have a record of training individuals who are from
underrepresented minority groups or from a rural or
disadvantaged background;
``(E) provide training in the care of vulnerable
populations such as children, older adults, homeless
individuals, victims of abuse or trauma, individuals with
mental health or substance-related disorders, individuals
with HIV/AIDS, and individuals with disabilities;
``(F) establish formal relationships and submit joint
applications with federally qualified
[[Page H2049]]
health centers, rural health clinics, area health education
centers, or clinics located in underserved areas or that
serve underserved populations;
``(G) teach trainees the skills to provide
interprofessional, integrated care through collaboration
among health professionals;
``(H) provide training in enhanced communication with
patients, evidence-based practice, chronic disease
management, preventive care, health information technology,
or other competencies as recommended by the Advisory
Committee on Training in Primary Care Medicine and Dentistry
and the National Health Care Workforce Commission established
in section 5101 of the Patient Protection and Affordable Care
Act; or
``(I) provide training in cultural competency and health
literacy.
``(4) Duration of awards.--The period during which payments
are made to an entity from an award of a grant or contract
under this subsection shall be 5 years.
``(c) Authorization of Appropriations.--
``(1) In general.--For purposes of carrying out this
section (other than subsection (b)(1)(B)), there are
authorized to be appropriated $125,000,000 for fiscal year
2010, and such sums as may be necessary for each of fiscal
years 2011 through 2014.
``(2) Training programs.--Fifteen percent of the amount
appropriated pursuant to paragraph (1) in each such fiscal
year shall be allocated to the physician assistant training
programs described in subsection (a)(1)(F), which prepare
students for practice in primary care.
``(3) Integrating academic administrative units.--For
purposes of carrying out subsection (b)(1)(B), there are
authorized to be appropriated $750,000 for each of fiscal
years 2010 through 2014.''.
SEC. 5302. TRAINING OPPORTUNITIES FOR DIRECT CARE WORKERS.
Part C of title VII of the Public Health Service Act (42
U.S.C. 293k et seq.) is amended by inserting after section
747, as amended by section 5301, the following:
``SEC. 747A. TRAINING OPPORTUNITIES FOR DIRECT CARE WORKERS.
``(a) In General.--The Secretary shall award grants to
eligible entities to enable such entities to provide new
training opportunities for direct care workers who are
employed in long-term care settings such as nursing homes (as
defined in section 1908(e)(1) of the Social Security Act (42
U.S.C. 1396g(e)(1)), assisted living facilities and skilled
nursing facilities, intermediate care facilities for
individuals with mental retardation, home and community based
settings, and any other setting the Secretary determines to
be appropriate.
``(b) Eligibility.--To be eligible to receive a grant under
this section, an entity shall--
``(1) be an institution of higher education (as defined in
section 102 of the Higher Education Act of 1965 (20 U.S.C.
1002)) that--
``(A) is accredited by a nationally recognized accrediting
agency or association listed under section 101(c) of the
Higher Education Act of 1965 (20 U.S.C. 1001(c)); and
``(B) has established a public-private educational
partnership with a nursing home or skilled nursing facility,
agency or entity providing home and community based services
to individuals with disabilities, or other long-term care
provider; and
``(2) submit to the Secretary an application at such time,
in such manner, and containing such information as the
Secretary may require.
``(c) Use of Funds.--An eligible entity shall use amounts
awarded under a grant under this section to provide
assistance to eligible individuals to offset the cost of
tuition and required fees for enrollment in academic programs
provided by such entity.
``(d) Eligible Individual.--
``(1) Eligibility.--To be eligible for assistance under
this section, an individual shall be enrolled in courses
provided by a grantee under this subsection and maintain
satisfactory academic progress in such courses.
``(2) Condition of assistance.--As a condition of receiving
assistance under this section, an individual shall agree
that, following completion of the assistance period, the
individual will work in the field of geriatrics, disability
services, long term services and supports, or chronic care
management for a minimum of 2 years under guidelines set by
the Secretary.
``(e) Authorization of Appropriations.--There is authorized
to be appropriated to carry out this section, $10,000,000 for
the period of fiscal years 2011 through 2013.''.
SEC. 5303. TRAINING IN GENERAL, PEDIATRIC, AND PUBLIC HEALTH
DENTISTRY.
Part C of Title VII of the Public Health Service Act (42
U.S.C. 293k et seq.) is amended by--
(1) redesignating section 748, as amended by section 5103
of this Act, as section 749; and
(2) inserting after section 747A, as added by section 5302,
the following:
``SEC. 748. TRAINING IN GENERAL, PEDIATRIC, AND PUBLIC HEALTH
DENTISTRY.
``(a) Support and Development of Dental Training
Programs.--
``(1) In general.--The Secretary may make grants to, or
enter into contracts with, a school of dentistry, public or
nonprofit private hospital, or a public or private nonprofit
entity which the Secretary has determined is capable of
carrying out such grant or contract--
``(A) to plan, develop, and operate, or participate in, an
approved professional training program in the field of
general dentistry, pediatric dentistry, or public health
dentistry for dental students, residents, practicing
dentists, dental hygienists, or other approved primary care
dental trainees, that emphasizes training for general,
pediatric, or public health dentistry;
``(B) to provide financial assistance to dental students,
residents, practicing dentists, and dental hygiene students
who are in need thereof, who are participants in any such
program, and who plan to work in the practice of general,
pediatric, public heath dentistry, or dental hygiene;
``(C) to plan, develop, and operate a program for the
training of oral health care providers who plan to teach in
general, pediatric, public health dentistry, or dental
hygiene;
``(D) to provide financial assistance in the form of
traineeships and fellowships to dentists who plan to teach or
are teaching in general, pediatric, or public health
dentistry;
``(E) to meet the costs of projects to establish, maintain,
or improve dental faculty development programs in primary
care (which may be departments, divisions or other units);
``(F) to meet the costs of projects to establish, maintain,
or improve predoctoral and postdoctoral training in primary
care programs;
``(G) to create a loan repayment program for faculty in
dental programs; and
``(H) to provide technical assistance to pediatric training
programs in developing and implementing instruction regarding
the oral health status, dental care needs, and risk-based
clinical disease management of all pediatric populations with
an emphasis on underserved children.
``(2) Faculty loan repayment.--
``(A) In general.--A grant or contract under subsection
(a)(1)(G) may be awarded to a program of general, pediatric,
or public health dentistry described in such subsection to
plan, develop, and operate a loan repayment program under
which--
``(i) individuals agree to serve full-time as faculty
members; and
``(ii) the program of general, pediatric or public health
dentistry agrees to pay the principal and interest on the
outstanding student loans of the individuals.
``(B) Manner of payments.--With respect to the payments
described in subparagraph (A)(ii), upon completion by an
individual of each of the first, second, third, fourth, and
fifth years of service, the program shall pay an amount equal
to 10, 15, 20, 25, and 30 percent, respectively, of the
individual's student loan balance as calculated based on
principal and interest owed at the initiation of the
agreement.
``(b) Eligible Entity.--For purposes of this subsection,
entities eligible for such grants or contracts in general,
pediatric, or public health dentistry shall include entities
that have programs in dental or dental hygiene schools, or
approved residency or advanced education programs in the
practice of general, pediatric, or public health dentistry.
Eligible entities may partner with schools of public health
to permit the education of dental students, residents, and
dental hygiene students for a master's year in public health
at a school of public health.
``(c) Priorities in Making Awards.--With respect to
training provided for under this section, the Secretary shall
give priority in awarding grants or contracts to the
following:
``(1) Qualified applicants that propose collaborative
projects between departments of primary care medicine and
departments of general, pediatric, or public health
dentistry.
``(2) Qualified applicants that have a record of training
the greatest percentage of providers, or that have
demonstrated significant improvements in the percentage of
providers, who enter and remain in general, pediatric, or
public health dentistry.
``(3) Qualified applicants that have a record of training
individuals who are from a rural or disadvantaged background,
or from underrepresented minorities.
``(4) Qualified applicants that establish formal
relationships with Federally qualified health centers, rural
health centers, or accredited teaching facilities and that
conduct training of students, residents, fellows, or faculty
at the center or facility.
``(5) Qualified applicants that conduct teaching programs
targeting vulnerable populations such as older adults,
homeless individuals, victims of abuse or trauma, individuals
with mental health or substance-related disorders,
individuals with disabilities, and individuals with HIV/AIDS,
and in the risk-based clinical disease management of all
populations.
``(6) Qualified applicants that include educational
activities in cultural competency and health literacy.
``(7) Qualified applicants that have a high rate for
placing graduates in practice settings that serve underserved
areas or health disparity populations, or who achieve a
significant increase in the rate of placing graduates in such
settings.
``(8) Qualified applicants that intend to establish a
special populations oral health care education center or
training program for the didactic and clinical education of
dentists, dental health professionals, and dental hygienists
who plan to teach oral health care for people with
developmental disabilities, cognitive impairment, complex
medical problems, significant physical limitations, and
vulnerable elderly.
``(d) Application.--An eligible entity desiring a grant
under this section shall submit to the Secretary an
application at such time, in such manner, and containing such
information as the Secretary may require.
``(e) Duration of Award.--The period during which payments
are made to an entity from an award of a grant or contract
under subsection (a) shall be 5 years. The provision of such
payments shall be subject to annual approval by the Secretary
and subject to the availability of appropriations for the
fiscal year involved to make the payments.
``(f) Authorizations of Appropriations.--For the purpose of
carrying out subsections (a) and (b), there is authorized to
be appropriated $30,000,000 for fiscal year 2010 and such
sums as may be necessary for each of fiscal years 2011
through 2015.
[[Page H2050]]
``(g) Carryover Funds.--An entity that receives an award
under this section may carry over funds from 1 fiscal year to
another without obtaining approval from the Secretary. In no
case may any funds be carried over pursuant to the preceding
sentence for more than 3 years.''.
SEC. 5304. ALTERNATIVE DENTAL HEALTH CARE PROVIDERS
DEMONSTRATION PROJECT.
Subpart X of part D of title III of the Public Health
Service Act (42 U.S.C. 256f et seq.) is amended by adding at
the end the following:
``SEC. 340G-1. DEMONSTRATION PROGRAM.
``(a) In General.--
``(1) Authorization.--The Secretary is authorized to award
grants to 15 eligible entities to enable such entities to
establish a demonstration program to establish training
programs to train, or to employ, alternative dental health
care providers in order to increase access to dental health
care services in rural and other underserved communities.
``(2) Definition.--The term `alternative dental health care
providers' includes community dental health coordinators,
advance practice dental hygienists, independent dental
hygienists, supervised dental hygienists, primary care
physicians, dental therapists, dental health aides, and any
other health professional that the Secretary determines
appropriate.
``(b) Timeframe.--The demonstration projects funded under
this section shall begin not later than 2 years after the
date of enactment of this section, and shall conclude not
later than 7 years after such date of enactment.
``(c) Eligible Entities.--To be eligible to receive a grant
under subsection (a), an entity shall--
``(1) be--
``(A) an institution of higher education, including a
community college;
``(B) a public-private partnership;
``(C) a federally qualified health center;
``(D) an Indian Health Service facility or a tribe or
tribal organization (as such terms are defined in section 4
of the Indian Self-Determination and Education Assistance
Act);
``(E) a State or county public health clinic, a health
facility operated by an Indian tribe or tribal organization,
or urban Indian organization providing dental services; or
``(F) a public hospital or health system;
``(2) be within a program accredited by the Commission on
Dental Accreditation or within a dental education program in
an accredited institution; and
``(3) shall submit an application to the Secretary at such
time, in such manner, and containing such information as the
Secretary may require.
``(d) Administrative Provisions.--
``(1) Amount of grant.--Each grant under this section shall
be in an amount that is not less than $4,000,000 for the 5-
year period during which the demonstration project being
conducted.
``(2) Disbursement of funds.--
``(A) Preliminary disbursements.--Beginning 1 year after
the enactment of this section, the Secretary may disperse to
any entity receiving a grant under this section not more than
20 percent of the total funding awarded to such entity under
such grant, for the purpose of enabling the entity to plan
the demonstration project to be conducted under such grant.
``(B) Subsequent disbursements.--The remaining amount of
grant funds not dispersed under subparagraph (A) shall be
dispersed such that not less than 15 percent of such
remaining amount is dispersed each subsequent year.
``(e) Compliance With State Requirements.--Each entity
receiving a grant under this section shall certify that it is
in compliance with all applicable State licensing
requirements.
``(f) Evaluation.--The Secretary shall contract with the
Director of the Institute of Medicine to conduct a study of
the demonstration programs conducted under this section that
shall provide analysis, based upon quantitative and
qualitative data, regarding access to dental health care in
the United States.
``(g) Clarification Regarding Dental Health Aide Program.--
Nothing in this section shall prohibit a dental health aide
training program approved by the Indian Health Service from
being eligible for a grant under this section.
``(h) Authorization of Appropriations.--There is authorized
to be appropriated such sums as may be necessary to carry out
this section.''.
SEC. 5305. GERIATRIC EDUCATION AND TRAINING; CAREER AWARDS;
COMPREHENSIVE GERIATRIC EDUCATION.
(a) Workforce Development; Career Awards.--Section 753 of
the Public Health Service Act (42 U.S.C. 294c) is amended by
adding at the end the following:
``(d) Geriatric Workforce Development.--
``(1) In general.--The Secretary shall award grants or
contracts under this subsection to entities that operate a
geriatric education center pursuant to subsection (a)(1).
``(2) Application.--To be eligible for an award under
paragraph (1), an entity described in such paragraph shall
submit to the Secretary an application at such time, in such
manner, and containing such information as the Secretary may
require.
``(3) Use of funds.--Amounts awarded under a grant or
contract under paragraph (1) shall be used to--
``(A) carry out the fellowship program described in
paragraph (4); and
``(B) carry out 1 of the 2 activities described in
paragraph (5).
``(4) Fellowship program.--
``(A) In general.--Pursuant to paragraph (3), a geriatric
education center that receives an award under this subsection
shall use such funds to offer short-term intensive courses
(referred to in this subsection as a `fellowship') that focus
on geriatrics, chronic care management, and long-term care
that provide supplemental training for faculty members in
medical schools and other health professions schools with
programs in psychology, pharmacy, nursing, social work,
dentistry, public health, allied health, or other health
disciplines, as approved by the Secretary. Such a fellowship
shall be open to current faculty, and appropriately
credentialed volunteer faculty and practitioners, who do not
have formal training in geriatrics, to upgrade their
knowledge and clinical skills for the care of older adults
and adults with functional limitations and to enhance their
interdisciplinary teaching skills.
``(B) Location.--A fellowship shall be offered either at
the geriatric education center that is sponsoring the course,
in collaboration with other geriatric education centers, or
at medical schools, schools of dentistry, schools of nursing,
schools of pharmacy, schools of social work, graduate
programs in psychology, or allied health and other health
professions schools approved by the Secretary with which the
geriatric education centers are affiliated.
``(C) CME credit.--Participation in a fellowship under this
paragraph shall be accepted with respect to complying with
continuing health profession education requirements. As a
condition of such acceptance, the recipient shall agree to
subsequently provide a minimum of 18 hours of voluntary
instructional support through a geriatric education center
that is providing clinical training to students or trainees
in long-term care settings.
``(5) Additional required activities described.--Pursuant
to paragraph (3), a geriatric education center that receives
an award under this subsection shall use such funds to carry
out 1 of the following 2 activities.
``(A) Family caregiver and direct care provider training.--
A geriatric education center that receives an award under
this subsection shall offer at least 2 courses each year, at
no charge or nominal cost, to family caregivers and direct
care providers that are designed to provide practical
training for supporting frail elders and individuals with
disabilities. The Secretary shall require such Centers to
work with appropriate community partners to develop training
program content and to publicize the availability of training
courses in their service areas. All family caregiver and
direct care provider training programs shall include
instruction on the management of psychological and behavioral
aspects of dementia, communication techniques for working
with individuals who have dementia, and the appropriate,
safe, and effective use of medications for older adults.
``(B) Incorporation of best practices.--A geriatric
education center that receives an award under this subsection
shall develop and include material on depression and other
mental disorders common among older adults, medication safety
issues for older adults, and management of the psychological
and behavioral aspects of dementia and communication
techniques with individuals who have dementia in all training
courses, where appropriate.
``(6) Targets.--A geriatric education center that receives
an award under this subsection shall meet targets approved by
the Secretary for providing geriatric training to a certain
number of faculty or practitioners during the term of the
award, as well as other parameters established by the
Secretary.
``(7) Amount of award.--An award under this subsection
shall be in an amount of $150,000. Not more than 24 geriatric
education centers may receive an award under this subsection.
``(8) Maintenance of effort.--A geriatric education center
that receives an award under this subsection shall provide
assurances to the Secretary that funds provided to the
geriatric education center under this subsection will be used
only to supplement, not to supplant, the amount of Federal,
State, and local funds otherwise expended by the geriatric
education center.
``(9) Authorization of appropriations.--In addition to any
other funding available to carry out this section, there is
authorized to be appropriated to carry out this subsection,
$10,800,000 for the period of fiscal year 2011 through 2014.
``(e) Geriatric Career Incentive Awards.--
``(1) In general.--The Secretary shall award grants or
contracts under this section to individuals described in
paragraph (2) to foster greater interest among a variety of
health professionals in entering the field of geriatrics,
long-term care, and chronic care management.
``(2) Eligible individuals.--To be eligible to received an
award under paragraph (1), an individual shall--
``(A) be an advanced practice nurse, a clinical social
worker, a pharmacist, or student of psychology who is
pursuing a doctorate or other advanced degree in geriatrics
or related fields in an accredited health professions school;
and
``(B) submit to the Secretary an application at such time,
in such manner, and containing such information as the
Secretary may require.
``(3) Condition of award.--As a condition of receiving an
award under this subsection, an individual shall agree that,
following completion of the award period, the individual will
teach or practice in the field of geriatrics, long-term care,
or chronic care management for a minimum of 5 years under
guidelines set by the Secretary.
``(4) Authorization of appropriations.--There is authorized
to be appropriated to carry out this subsection, $10,000,000
for the period of fiscal years 2011 through 2013.''.
(b) Expansion of Eligibility for Geriatric Academic Career
Awards; Payment to Institution.--Section 753(c) of the Public
Health Service Act 294(c)) is amended--
(1) by redesignating paragraphs (4) and (5) as paragraphs
(5) and (6), respectively;
(2) by striking paragraph (2) through paragraph (3) and
inserting the following:
[[Page H2051]]
``(2) Eligible individuals.--To be eligible to receive an
Award under paragraph (1), an individual shall--
``(A) be board certified or board eligible in internal
medicine, family practice, psychiatry, or licensed dentistry,
or have completed any required training in a discipline and
employed in an accredited health professions school that is
approved by the Secretary;
``(B) have completed an approved fellowship program in
geriatrics or have completed specialty training in geriatrics
as required by the discipline and any addition geriatrics
training as required by the Secretary; and
``(C) have a junior (non-tenured) faculty appointment at an
accredited (as determined by the Secretary) school of
medicine, osteopathic medicine, nursing, social work,
psychology, dentistry, pharmacy, or other allied health
disciplines in an accredited health professions school that
is approved by the Secretary.
``(3) Limitations.--No Award under paragraph (1) may be
made to an eligible individual unless the individual--
``(A) has submitted to the Secretary an application, at
such time, in such manner, and containing such information as
the Secretary may require, and the Secretary has approved
such application;
``(B) provides, in such form and manner as the Secretary
may require, assurances that the individual will meet the
service requirement described in paragraph (6); and
``(C) provides, in such form and manner as the Secretary
may require, assurances that the individual has a full-time
faculty appointment in a health professions institution and
documented commitment from such institution to spend 75
percent of the total time of such individual on teaching and
developing skills in interdisciplinary education in
geriatrics.
``(4) Maintenance of effort.--An eligible individual that
receives an Award under paragraph (1) shall provide
assurances to the Secretary that funds provided to the
eligible individual under this subsection will be used only
to supplement, not to supplant, the amount of Federal, State,
and local funds otherwise expended by the eligible
individual.''; and
(3) in paragraph (5), as so designated--
(A) in subparagraph (A)--
(i) by inserting ``for individuals who are physicians''
after ``this section''; and
(ii) by inserting after the period at the end the
following: ``The Secretary shall determine the amount of an
Award under this section for individuals who are not
physicians.''; and
(B) by adding at the end the following:
``(C) Payment to institution.--The Secretary shall make
payments to institutions which include schools of medicine,
osteopathic medicine, nursing, social work, psychology,
dentistry, and pharmacy, or other allied health discipline in
an accredited health professions school that is approved by
the Secretary.''.
(c) Comprehensive Geriatric Education.--Section 855 of the
Public Health Service Act (42 U.S.C. 298) is amended--
(1) in subsection (b)--
(A) in paragraph (3), by striking ``or'' at the end;
(B) in paragraph (4), by striking the period and inserting
``; or''; and
(C) by adding at the end the following:
``(5) establish traineeships for individuals who are
preparing for advanced education nursing degrees in geriatric
nursing, long-term care, gero-psychiatric nursing or other
nursing areas that specialize in the care of the elderly
population.''; and
(2) in subsection (e), by striking ``2003 through 2007''
and inserting ``2010 through 2014''.
SEC. 5306. MENTAL AND BEHAVIORAL HEALTH EDUCATION AND
TRAINING GRANTS.
(a) In General.--Part D of title VII (42 U.S.C. 294 et
seq.) is amended by--
(1) striking section 757;
(2) redesignating section 756 (as amended by section 5103)
as section 757; and
(3) inserting after section 755 the following:
``SEC. 756. MENTAL AND BEHAVIORAL HEALTH EDUCATION AND
TRAINING GRANTS.
``(a) Grants Authorized.--The Secretary may award grants to
eligible institutions of higher education to support the
recruitment of students for, and education and clinical
experience of the students in--
``(1) baccalaureate, master's, and doctoral degree programs
of social work, as well as the development of faculty in
social work;
``(2) accredited master's, doctoral, internship, and post-
doctoral residency programs of psychology for the development
and implementation of interdisciplinary training of
psychology graduate students for providing behavioral and
mental health services, including substance abuse prevention
and treatment services;
``(3) accredited institutions of higher education or
accredited professional training programs that are
establishing or expanding internships or other field
placement programs in child and adolescent mental health in
psychiatry, psychology, school psychology, behavioral
pediatrics, psychiatric nursing, social work, school social
work, substance abuse prevention and treatment, marriage and
family therapy, school counseling, or professional
counseling; and
``(4) State-licensed mental health nonprofit and for-profit
organizations to enable such organizations to pay for
programs for preservice or in-service training of
paraprofessional child and adolescent mental health workers.
``(b) Eligibility Requirements.--To be eligible for a grant
under this section, an institution shall demonstrate--
``(1) participation in the institutions' programs of
individuals and groups from different racial, ethnic,
cultural, geographic, religious, linguistic, and class
backgrounds, and different genders and sexual orientations;
``(2) knowledge and understanding of the concerns of the
individuals and groups described in subsection (a);
``(3) any internship or other field placement program
assisted under the grant will prioritize cultural and
linguistic competency;
``(4) the institution will provide to the Secretary such
data, assurances, and information as the Secretary may
require; and
``(5) with respect to any violation of the agreement
between the Secretary and the institution, the institution
will pay such liquidated damages as prescribed by the
Secretary by regulation.
``(c) Institutional Requirement.--For grants authorized
under subsection (a)(1), at least 4 of the grant recipients
shall be historically black colleges or universities or other
minority-serving institutions.
``(d) Priority.--
``(1) In selecting the grant recipients in social work
under subsection (a)(1), the Secretary shall give priority to
applicants that--
``(A) are accredited by the Council on Social Work
Education;
``(B) have a graduation rate of not less than 80 percent
for social work students; and
``(C) exhibit an ability to recruit social workers from and
place social workers in areas with a high need and high
demand population.
``(2) In selecting the grant recipients in graduate
psychology under subsection (a)(2), the Secretary shall give
priority to institutions in which training focuses on the
needs of vulnerable groups such as older adults and children,
individuals with mental health or substance-related
disorders, victims of abuse or trauma and of combat stress
disorders such as posttraumatic stress disorder and traumatic
brain injuries, homeless individuals, chronically ill
persons, and their families.
``(3) In selecting the grant recipients in training
programs in child and adolescent mental health under
subsections (a)(3) and (a)(4), the Secretary shall give
priority to applicants that--
``(A) have demonstrated the ability to collect data on the
number of students trained in child and adolescent mental
health and the populations served by such students after
graduation or completion of preservice or in-service
training;
``(B) have demonstrated familiarity with evidence-based
methods in child and adolescent mental health services,
including substance abuse prevention and treatment services;
``(C) have programs designed to increase the number of
professionals and paraprofessionals serving high-priority
populations and to applicants who come from high-priority
communities and plan to serve medically underserved
populations, in health professional shortage areas, or in
medically underserved areas;
``(D) offer curriculum taught collaboratively with a family
on the consumer and family lived experience or the importance
of family-professional or family-paraprofessional
partnerships; and
``(E) provide services through a community mental health
program described in section 1913(b)(1).
``(e) Authorization of Appropriation.--For the fiscal years
2010 through 2013, there is authorized to be appropriated to
carry out this section--
``(1) $8,000,000 for training in social work in subsection
(a)(1);
``(2) $12,000,000 for training in graduate psychology in
subsection (a)(2), of which not less than $10,000,000 shall
be allocated for doctoral, postdoctoral, and internship level
training;
``(3) $10,000,000 for training in professional child and
adolescent mental health in subsection (a)(3); and
``(4) $5,000,000 for training in paraprofessional child and
adolescent work in subsection (a)(4).''.
(b) Conforming Amendments.--Section 757(b)(2) of the Public
Health Service Act, as redesignated by subsection (a), is
amended by striking ``sections 751(a)(1)(A), 751(a)(1)(B),
753(b), 754(3)(A), and 755(b)'' and inserting ``sections
751(b)(1)(A), 753(b), and 755(b)''.
SEC. 5307. CULTURAL COMPETENCY, PREVENTION, AND PUBLIC HEALTH
AND INDIVIDUALS WITH DISABILITIES TRAINING.
(a) Title VII.--Section 741 of the Public Health Service
Act (42 U.S.C. 293e) is amended--
(1) in subsection (a)--
(A) by striking the subsection heading and inserting
``Cultural Competency, Prevention, and Public Health and
Individuals With Disability Grants''; and
(B) in paragraph (1), by striking ``for the purpose of''
and all that follows through the period at the end and
inserting ``for the development, evaluation, and
dissemination of research, demonstration projects, and model
curricula for cultural competency, prevention, public health
proficiency, reducing health disparities, and aptitude for
working with individuals with disabilities training for use
in health professions schools and continuing education
programs, and for other purposes determined as appropriate by
the Secretary.''; and
(2) by striking subsection (b) and inserting the following:
``(b) Collaboration.--In carrying out subsection (a), the
Secretary shall collaborate with health professional
societies, licensing and accreditation entities, health
professions schools, and experts in minority health and
cultural competency, prevention, and public health and
disability groups, community-based organizations, and other
organizations as determined appropriate by the Secretary. The
Secretary shall coordinate with curricula and research and
demonstration projects developed under section 807.
``(c) Dissemination.--
``(1) In general.--Model curricula developed under this
section shall be disseminated through the Internet
Clearinghouse under section 270 and such other means as
determined appropriate by the Secretary.
``(2) Evaluation.--The Secretary shall evaluate the
adoption and the implementation of cultural competency,
prevention, and public
[[Page H2052]]
health, and working with individuals with a disability
training curricula, and the facilitate inclusion of these
competency measures in quality measurement systems as
appropriate.
``(d) Authorization of Appropriations.--There is authorized
to be appropriated to carry out this section such sums as may
be necessary for each of fiscal years 2010 through 2015.''.
(b) Title VIII.--Section 807 of the Public Health Service
Act (42 U.S.C. 296e-1) is amended--
(1) in subsection (a)--
(A) by striking the subsection heading and inserting
``Cultural Competency, Prevention, and Public Health and
Individuals With Disability Grants''; and
(B) by striking ``for the purpose of'' and all that follows
through ``health care.'' and inserting ``for the development,
evaluation, and dissemination of research, demonstration
projects, and model curricula for cultural competency,
prevention, public health proficiency, reducing health
disparities, and aptitude for working with individuals with
disabilities training for use in health professions schools
and continuing education programs, and for other purposes
determined as appropriate by the Secretary.''; and
(2) by redesignating subsection (b) as subsection (d);
(3) by inserting after subsection (a) the following:
``(b) Collaboration.--In carrying out subsection (a), the
Secretary shall collaborate with the entities described in
section 741(b). The Secretary shall coordinate with curricula
and research and demonstration projects developed under such
section 741.
``(c) Dissemination.--Model curricula developed under this
section shall be disseminated and evaluated in the same
manner as model curricula developed under section 741, as
described in subsection (c) of such section.''; and
(4) in subsection (d), as so redesignated--
(A) by striking ``subsection (a)'' and inserting ``this
section''; and
(B) by striking ``2001 through 2004'' and inserting ``2010
through 2015''.
SEC. 5308. ADVANCED NURSING EDUCATION GRANTS.
Section 811 of the Public Health Service Act (42 U.S.C.
296j) is amended--
(1) in subsection (c)--
(A) in the subsection heading, by striking ``and Nurse
Midwifery Programs''; and
(B) by striking ``and nurse midwifery'';
(2) in subsection (f)--
(A) by striking paragraph (2); and
(B) by redesignating paragraph (3) as paragraph (2); and
(3) by redesignating subsections (d), (e), and (f) as
subsections (e), (f), and (g), respectively; and
(4) by inserting after subsection (c), the following:
``(d) Authorized Nurse-midwifery Programs.--Midwifery
programs that are eligible for support under this section are
educational programs that--
``(1) have as their objective the education of midwives;
and
``(2) are accredited by the American College of Nurse-
Midwives Accreditation Commission for Midwifery Education.''.
SEC. 5309. NURSE EDUCATION, PRACTICE, AND RETENTION GRANTS.
(a) In General.--Section 831 of the Public Health Service
Act (42 U.S.C. 296p) is amended--
(1) in the section heading, by striking ``RETENTION'' and
inserting ``QUALITY'';
(2) in subsection (a)--
(A) in paragraph (1), by adding ``or'' after the semicolon;
(B) by striking paragraph (2); and
(C) by redesignating paragraph (3) as paragraph (2);
(3) in subsection (b)(3), by striking ``managed care,
quality improvement'' and inserting ``coordinated care'';
(4) in subsection (g), by inserting ``, as defined in
section 801(2),'' after ``school of nursing''; and
(5) in subsection (h), by striking ``2003 through 2007''
and inserting ``2010 through 2014''.
(b) Nurse Retention Grants.--Title VIII of the Public
Health Service Act is amended by inserting after section 831
(42 U.S.C. 296b) the following:
``SEC. 831A. NURSE RETENTION GRANTS.
``(a) Retention Priority Areas.--The Secretary may award
grants to, and enter into contracts with, eligible entities
to enhance the nursing workforce by initiating and
maintaining nurse retention programs pursuant to subsection
(b) or (c).
``(b) Grants for Career Ladder Program.--The Secretary may
award grants to, and enter into contracts with, eligible
entities for programs--
``(1) to promote career advancement for individuals
including licensed practical nurses, licensed vocational
nurses, certified nurse assistants, home health aides,
diploma degree or associate degree nurses, to become
baccalaureate prepared registered nurses or advanced
education nurses in order to meet the needs of the registered
nurse workforce;
``(2) developing and implementing internships and residency
programs in collaboration with an accredited school of
nursing, as defined by section 801(2), to encourage mentoring
and the development of specialties; or
``(3) to assist individuals in obtaining education and
training required to enter the nursing profession and advance
within such profession.
``(c) Enhancing Patient Care Delivery Systems.--
``(1) Grants.--The Secretary may award grants to eligible
entities to improve the retention of nurses and enhance
patient care that is directly related to nursing activities
by enhancing collaboration and communication among nurses and
other health care professionals, and by promoting nurse
involvement in the organizational and clinical decision-
making processes of a health care facility.
``(2) Priority.--In making awards of grants under this
subsection, the Secretary shall give preference to applicants
that have not previously received an award under this
subsection (or section 831(c) as such section existed on the
day before the date of enactment of this section).
``(3) Continuation of an award.--The Secretary shall make
continuation of any award under this subsection beyond the
second year of such award contingent on the recipient of such
award having demonstrated to the Secretary measurable and
substantive improvement in nurse retention or patient care.
``(d) Other Priority Areas.--The Secretary may award grants
to, or enter into contracts with, eligible entities to
address other areas that are of high priority to nurse
retention, as determined by the Secretary.
``(e) Report.--The Secretary shall submit to the Congress
before the end of each fiscal year a report on the grants
awarded and the contracts entered into under this section.
Each such report shall identify the overall number of such
grants and contracts and provide an explanation of why each
such grant or contract will meet the priority need of the
nursing workforce.
``(f) Eligible Entity.--For purposes of this section, the
term `eligible entity' includes an accredited school of
nursing, as defined by section 801(2), a health care
facility, or a partnership of such a school and facility.
``(g) Authorization of Appropriations.--There are
authorized to be appropriated to carry out this section such
sums as may be necessary for each of fiscal years 2010
through 2012.''.
SEC. 5310. LOAN REPAYMENT AND SCHOLARSHIP PROGRAM.
(a) Loan Repayments and Scholarships.--Section 846(a)(3) of
the Public Health Service Act (42 U.S.C. 297n(a)(3)) is
amended by inserting before the semicolon the following: ``,
or in a accredited school of nursing, as defined by section
801(2), as nurse faculty''.
(b) Technical and Conforming Amendments.--Title VIII (42
U.S.C. 296 et seq.) is amended--
(1) by redesignating section 810 (relating to prohibition
against discrimination by schools on the basis of sex) as
section 809 and moving such section so that it follows
section 808;
(2) in sections 835, 836, 838, 840, and 842, by striking
the term ``this subpart'' each place it appears and inserting
``this part'';
(3) in section 836(h), by striking the last sentence;
(4) in section 836, by redesignating subsection (l) as
subsection (k);
(5) in section 839, by striking ``839'' and all that
follows through ``(a)'' and inserting ``839. (a)'';
(6) in section 835(b), by striking ``841'' each place it
appears and inserting ``871'';
(7) by redesignating section 841 as section 871, moving
part F to the end of the title, and redesignating such part
as part I;
(8) in part G--
(A) by redesignating section 845 as section 851; and
(B) by redesignating part G as part F;
(9) in part H--
(A) by redesignating sections 851 and 852 as sections 861
and 862, respectively; and
(B) by redesignating part H as part G; and
(10) in part I--
(A) by redesignating section 855, as amended by section
5305, as section 865; and
(B) by redesignating part I as part H.
SEC. 5311. NURSE FACULTY LOAN PROGRAM.
(a) In General.--Section 846A of the Public Health Service
Act (42 U.S.C. 297n-1) is amended--
(1) in subsection (a)--
(A) in the subsection heading, by striking
``Establishment'' and inserting ``School of Nursing Student
Loan Fund''; and
(B) by inserting ``accredited'' after ``agreement with
any'';
(2) in subsection (c)--
(A) in paragraph (2), by striking ``$30,000'' and all that
follows through the semicolon and inserting ``$35,500, during
fiscal years 2010 and 2011 fiscal years (after fiscal year
2011, such amounts shall be adjusted to provide for a cost-
of-attendance increase for the yearly loan rate and the
aggregate loan;''; and
(B) in paragraph (3)(A), by inserting ``an accredited''
after ``faculty member in'';
(3) in subsection (e), by striking ``a school'' and
inserting ``an accredited school''; and
(4) in subsection (f), by striking ``2003 through 2007''
and inserting ``2010 through 2014''.
(b) Eligible Individual Student Loan Repayment.--Title VIII
of the Public Health Service Act is amended by inserting
after section 846A (42 U.S.C. 297n-1) the following:
``SEC. 847. ELIGIBLE INDIVIDUAL STUDENT LOAN REPAYMENT.
``(a) In General.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration, may enter into an agreement with eligible
individuals for the repayment of education loans, in
accordance with this section, to increase the number of
qualified nursing faculty.
``(b) Agreements.--Each agreement entered into under this
subsection shall require that the eligible individual shall
serve as a full-time member of the faculty of an accredited
school of nursing, for a total period, in the aggregate, of
at least 4 years during the 6-year period beginning on the
later of--
``(1) the date on which the individual receives a master's
or doctorate nursing degree from an accredited school of
nursing; or
``(2) the date on which the individual enters into an
agreement under this subsection.
[[Page H2053]]
``(c) Agreement Provisions.--Agreements entered into
pursuant to subsection (b) shall be entered into on such
terms and conditions as the Secretary may determine, except
that--
``(1) not more than 10 months after the date on which the
6-year period described under subsection (b) begins, but in
no case before the individual starts as a full-time member of
the faculty of an accredited school of nursing the Secretary
shall begin making payments, for and on behalf of that
individual, on the outstanding principal of, and interest on,
any loan of that individual obtained to pay for such degree;
``(2) for an individual who has completed a master's in
nursing or equivalent degree in nursing--
``(A) payments may not exceed $10,000 per calendar year;
and
``(B) total payments may not exceed $40,000 during the 2010
and 2011 fiscal years (after fiscal year 2011, such amounts
shall be adjusted to provide for a cost-of-attendance
increase for the yearly loan rate and the aggregate loan);
and
``(3) for an individual who has completed a doctorate or
equivalent degree in nursing--
``(A) payments may not exceed $20,000 per calendar year;
and
``(B) total payments may not exceed $80,000 during the 2010
and 2011 fiscal years (adjusted for subsequent fiscal years
as provided for in the same manner as in paragraph (2)(B)).
``(d) Breach of Agreement.--
``(1) In general.--In the case of any agreement made under
subsection (b), the individual is liable to the Federal
Government for the total amount paid by the Secretary under
such agreement, and for interest on such amount at the
maximum legal prevailing rate, if the individual fails to
meet the agreement terms required under such subsection.
``(2) Waiver or suspension of liability.--In the case of an
individual making an agreement for purposes of paragraph (1),
the Secretary shall provide for the waiver or suspension of
liability under such paragraph if compliance by the
individual with the agreement involved is impossible or would
involve extreme hardship to the individual or if enforcement
of the agreement with respect to the individual would be
unconscionable.
``(3) Date certain for recovery.--Subject to paragraph (2),
any amount that the Federal Government is entitled to recover
under paragraph (1) shall be paid to the United States not
later than the expiration of the 3-year period beginning on
the date the United States becomes so entitled.
``(4) Availability.--Amounts recovered under paragraph (1)
shall be available to the Secretary for making loan
repayments under this section and shall remain available for
such purpose until expended.
``(e) Eligible Individual Defined.--For purposes of this
section, the term `eligible individual' means an individual
who--
``(1) is a United States citizen, national, or lawful
permanent resident;
``(2) holds an unencumbered license as a registered nurse;
and
``(3) has either already completed a master's or doctorate
nursing program at an accredited school of nursing or is
currently enrolled on a full-time or part-time basis in such
a program.
``(f) Priority.--For the purposes of this section and
section 846A, funding priority will be awarded to School of
Nursing Student Loans that support doctoral nursing students
or Individual Student Loan Repayment that support doctoral
nursing students.
``(g) Authorization of Appropriations.--There are
authorized to be appropriated to carry out this section such
sums as may be necessary for each of fiscal years 2010
through 2014.''.
SEC. 5312. AUTHORIZATION OF APPROPRIATIONS FOR PARTS B
THROUGH D OF TITLE VIII.
Section 871 of the Public Health Service Act, as
redesignated and moved by section 5310, is amended to read as
follows:
``SEC. 871. AUTHORIZATION OF APPROPRIATIONS.
``For the purpose of carrying out parts B, C, and D
(subject to section 851(g)), there are authorized to be
appropriated $338,000,000 for fiscal year 2010, and such sums
as may be necessary for each of the fiscal years 2011 through
2016.''.
SEC. 5313. GRANTS TO PROMOTE THE COMMUNITY HEALTH WORKFORCE.
(a) In General.--Part P of title III of the Public Health
Service Act (42 U.S.C. 280g et seq.) is amended by adding at
the end the following:
``SEC. 399V. GRANTS TO PROMOTE POSITIVE HEALTH BEHAVIORS AND
OUTCOMES.
``(a) Grants Authorized.--The Director of the Centers for
Disease Control and Prevention, in collaboration with the
Secretary, shall award grants to eligible entities to promote
positive health behaviors and outcomes for populations in
medically underserved communities through the use of
community health workers.
``(b) Use of Funds.--Grants awarded under subsection (a)
shall be used to support community health workers--
``(1) to educate, guide, and provide outreach in a
community setting regarding health problems prevalent in
medically underserved communities, particularly racial and
ethnic minority populations;
``(2) to educate and provide guidance regarding effective
strategies to promote positive health behaviors and
discourage risky health behaviors;
``(3) to educate and provide outreach regarding enrollment
in health insurance including the Children's Health Insurance
Program under title XXI of the Social Security Act, Medicare
under title XVIII of such Act and Medicaid under title XIX of
such Act;
``(4) to identify, educate, refer, and enroll underserved
populations to appropriate healthcare agencies and community-
based programs and organizations in order to increase access
to quality healthcare services and to eliminate duplicative
care; or
``(5) to educate, guide, and provide home visitation
services regarding maternal health and prenatal care.
``(c) Application.--Each eligible entity that desires to
receive a grant under subsection (a) shall submit an
application to the Secretary, at such time, in such manner,
and accompanied by such information as the Secretary may
require.
``(d) Priority.--In awarding grants under subsection (a),
the Secretary shall give priority to applicants that--
``(1) propose to target geographic areas--
``(A) with a high percentage of residents who are eligible
for health insurance but are uninsured or underinsured;
``(B) with a high percentage of residents who suffer from
chronic diseases; or
``(C) with a high infant mortality rate;
``(2) have experience in providing health or health-related
social services to individuals who are underserved with
respect to such services; and
``(3) have documented community activity and experience
with community health workers.
``(e) Collaboration With Academic Institutions and the One-
stop Delivery System.--The Secretary shall encourage
community health worker programs receiving funds under this
section to collaborate with academic institutions and one-
stop delivery systems under section 134(c) of the Workforce
Investment Act of 1998. Nothing in this section shall be
construed to require such collaboration.
``(f) Evidence-based Interventions.--The Secretary shall
encourage community health worker programs receiving funding
under this section to implement a process or an outcome-based
payment system that rewards community health workers for
connecting underserved populations with the most appropriate
services at the most appropriate time. Nothing in this
section shall be construed to require such a payment.
``(g) Quality Assurance and Cost Effectiveness.--The
Secretary shall establish guidelines for assuring the quality
of the training and supervision of community health workers
under the programs funded under this section and for assuring
the cost-effectiveness of such programs.
``(h) Monitoring.--The Secretary shall monitor community
health worker programs identified in approved applications
under this section and shall determine whether such programs
are in compliance with the guidelines established under
subsection (g).
``(i) Technical Assistance.--The Secretary may provide
technical assistance to community health worker programs
identified in approved applications under this section with
respect to planning, developing, and operating programs under
the grant.
``(j) Authorization of Appropriations.--There are
authorized to be appropriated, such sums as may be necessary
to carry out this section for each of fiscal years 2010
through 2014.
``(k) Definitions.--In this section:
``(1) Community health worker.--The term `community health
worker', as defined by the Department of Labor as Standard
Occupational Classification [21-1094] means an individual who
promotes health or nutrition within the community in which
the individual resides--
``(A) by serving as a liaison between communities and
healthcare agencies;
``(B) by providing guidance and social assistance to
community residents;
``(C) by enhancing community residents' ability to
effectively communicate with healthcare providers;
``(D) by providing culturally and linguistically
appropriate health or nutrition education;
``(E) by advocating for individual and community health;
``(F) by providing referral and follow-up services or
otherwise coordinating care; and
``(G) by proactively identifying and enrolling eligible
individuals in Federal, State, local, private or nonprofit
health and human services programs.
``(2) Community setting.--The term `community setting'
means a home or a community organization located in the
neighborhood in which a participant in the program under this
section resides.
``(3) Eligible entity.--The term `eligible entity' means a
public or nonprofit private entity (including a State or
public subdivision of a State, a public health department, a
free health clinic, a hospital, or a Federally-qualified
health center (as defined in section 1861(aa) of the Social
Security Act)), or a consortium of any such entities.
``(4) Medically underserved community.--The term `medically
underserved community' means a community identified by a
State--
``(A) that has a substantial number of individuals who are
members of a medically underserved population, as defined by
section 330(b)(3); and
``(B) a significant portion of which is a health
professional shortage area as designated under section
332.''.
SEC. 5314. FELLOWSHIP TRAINING IN PUBLIC HEALTH.
Part E of title VII of the Public Health Service Act (42
U.S.C. 294n et seq.), as amended by section 5206, is further
amended by adding at the end the following:
``SEC. 778. FELLOWSHIP TRAINING IN APPLIED PUBLIC HEALTH
EPIDEMIOLOGY, PUBLIC HEALTH LABORATORY SCIENCE,
PUBLIC HEALTH INFORMATICS, AND EXPANSION OF THE
EPIDEMIC INTELLIGENCE SERVICE.
``(a) In General.--The Secretary may carry out activities
to address documented workforce shortages in State and local
health departments in the critical areas of applied public
health epidemiology and public health laboratory science
[[Page H2054]]
and informatics and may expand the Epidemic Intelligence
Service.
``(b) Specific Uses.--In carrying out subsection (a), the
Secretary shall provide for the expansion of existing
fellowship programs operated through the Centers for Disease
Control and Prevention in a manner that is designed to
alleviate shortages of the type described in subsection (a).
``(c) Other Programs.--The Secretary may provide for the
expansion of other applied epidemiology training programs
that meet objectives similar to the objectives of the
programs described in subsection (b).
``(d) Work Obligation.--Participation in fellowship
training programs under this section shall be deemed to be
service for purposes of satisfying work obligations
stipulated in contracts under section 338I(j).
``(e) General Support.--Amounts may be used from grants
awarded under this section to expand the Public Health
Informatics Fellowship Program at the Centers for Disease
Control and Prevention to better support all public health
systems at all levels of government.
``(f) Authorization of Appropriations.--There are
authorized to be appropriated to carry out this section
$39,500,000 for each of fiscal years 2010 through 2013, of
which--
``(1) $5,000,000 shall be made available in each such
fiscal year for epidemiology fellowship training program
activities under subsections (b) and (c);
``(2) $5,000,000 shall be made available in each such
fiscal year for laboratory fellowship training programs under
subsection (b);
``(3) $5,000,000 shall be made available in each such
fiscal year for the Public Health Informatics Fellowship
Program under subsection (e); and
``(4) $24,500,000 shall be made available for expanding the
Epidemic Intelligence Service under subsection (a).''.
SEC. 5315. UNITED STATES PUBLIC HEALTH SCIENCES TRACK.
Title II of the Public Health Service Act (42 U.S.C. 202 et
seq.) is amended by adding at the end the following:
``PART D--UNITED STATES PUBLIC HEALTH SCIENCES TRACK
``SEC. 271. ESTABLISHMENT.
``(a) United States Public Health Services Track.--
``(1) In general.--There is hereby authorized to be
established a United States Public Health Sciences Track
(referred to in this part as the `Track'), at sites to be
selected by the Secretary, with authority to grant
appropriate advanced degrees in a manner that uniquely
emphasizes team-based service, public health, epidemiology,
and emergency preparedness and response. It shall be so
organized as to graduate not less than--
``(A) 150 medical students annually, 10 of whom shall be
awarded studentships to the Uniformed Services University of
Health Sciences;
``(B) 100 dental students annually;
``(C) 250 nursing students annually;
``(D) 100 public health students annually;
``(E) 100 behavioral and mental health professional
students annually;
``(F) 100 physician assistant or nurse practitioner
students annually; and
``(G) 50 pharmacy students annually.
``(2) Locations.--The Track shall be located at existing
and accredited, affiliated health professions education
training programs at academic health centers located in
regions of the United States determined appropriate by the
Surgeon General, in consultation with the National Health
Care Workforce Commission established in section 5101 of the
Patient Protection and Affordable Care Act.
``(b) Number of Graduates.--Except as provided in
subsection (a), the number of persons to be graduated from
the Track shall be prescribed by the Secretary. In so
prescribing the number of persons to be graduated from the
Track, the Secretary shall institute actions necessary to
ensure the maximum number of first-year enrollments in the
Track consistent with the academic capacity of the affiliated
sites and the needs of the United States for medical, dental,
and nursing personnel.
``(c) Development.--The development of the Track may be by
such phases as the Secretary may prescribe subject to the
requirements of subsection (a).
``(d) Integrated Longitudinal Plan.--The Surgeon General
shall develop an integrated longitudinal plan for health
professions continuing education throughout the continuum of
health-related education, training, and practice. Training
under such plan shall emphasize patient-centered,
interdisciplinary, and care coordination skills. Experience
with deployment of emergency response teams shall be included
during the clinical experiences.
``(e) Faculty Development.--The Surgeon General shall
develop faculty development programs and curricula in
decentralized venues of health care, to balance urban,
tertiary, and inpatient venues.
``SEC. 272. ADMINISTRATION.
``(a) In General.--The business of the Track shall be
conducted by the Surgeon General with funds appropriated for
and provided by the Department of Health and Human Services.
The National Health Care Workforce Commission shall assist
the Surgeon General in an advisory capacity.
``(b) Faculty.--
``(1) In general.--The Surgeon General, after considering
the recommendations of the National Health Care Workforce
Commission, shall obtain the services of such professors,
instructors, and administrative and other employees as may be
necessary to operate the Track, but utilize when possible,
existing affiliated health professions training institutions.
Members of the faculty and staff shall be employed under
salary schedules and granted retirement and other related
benefits prescribed by the Secretary so as to place the
employees of the Track faculty on a comparable basis with the
employees of fully accredited schools of the health
professions within the United States.
``(2) Titles.--The Surgeon General may confer academic
titles, as appropriate, upon the members of the faculty.
``(3) Nonapplication of provisions.--The limitations in
section 5373 of title 5, United States Code, shall not apply
to the authority of the Surgeon General under paragraph (1)
to prescribe salary schedules and other related benefits.
``(c) Agreements.--The Surgeon General may negotiate
agreements with agencies of the Federal Government to utilize
on a reimbursable basis appropriate existing Federal medical
resources located in the United States (or locations selected
in accordance with section 271(a)(2)). Under such agreements
the facilities concerned will retain their identities and
basic missions. The Surgeon General may negotiate affiliation
agreements with accredited universities and health
professions training institutions in the United States. Such
agreements may include provisions for payments for
educational services provided students participating in
Department of Health and Human Services educational programs.
``(d) Programs.--The Surgeon General may establish the
following educational programs for Track students:
``(1) Postdoctoral, postgraduate, and technological
programs.
``(2) A cooperative program for medical, dental, physician
assistant, pharmacy, behavioral and mental health, public
health, and nursing students.
``(3) Other programs that the Surgeon General determines
necessary in order to operate the Track in a cost-effective
manner.
``(e) Continuing Medical Education.--The Surgeon General
shall establish programs in continuing medical education for
members of the health professions to the end that high
standards of health care may be maintained within the United
States.
``(f) Authority of the Surgeon General.--
``(1) In general.--The Surgeon General is authorized--
``(A) to enter into contracts with, accept grants from, and
make grants to any nonprofit entity for the purpose of
carrying out cooperative enterprises in medical, dental,
physician assistant, pharmacy, behavioral and mental health,
public health, and nursing research, consultation, and
education;
``(B) to enter into contracts with entities under which the
Surgeon General may furnish the services of such
professional, technical, or clerical personnel as may be
necessary to fulfill cooperative enterprises undertaken by
the Track;
``(C) to accept, hold, administer, invest, and spend any
gift, devise, or bequest of personal property made to the
Track, including any gift, devise, or bequest for the support
of an academic chair, teaching, research, or demonstration
project;
``(D) to enter into agreements with entities that may be
utilized by the Track for the purpose of enhancing the
activities of the Track in education, research, and
technological applications of knowledge; and
``(E) to accept the voluntary services of guest scholars
and other persons.
``(2) Limitation.--The Surgeon General may not enter into
any contract with an entity if the contract would obligate
the Track to make outlays in advance of the enactment of
budget authority for such outlays.
``(3) Scientists.--Scientists or other medical, dental, or
nursing personnel utilized by the Track under an agreement
described in paragraph (1) may be appointed to any position
within the Track and may be permitted to perform such duties
within the Track as the Surgeon General may approve.
``(4) Volunteer services.--A person who provides voluntary
services under the authority of subparagraph (E) of paragraph
(1) shall be considered to be an employee of the Federal
Government for the purposes of chapter 81 of title 5,
relating to compensation for work-related injuries, and to be
an employee of the Federal Government for the purposes of
chapter 171 of title 28, relating to tort claims. Such a
person who is not otherwise employed by the Federal
Government shall not be considered to be a Federal employee
for any other purpose by reason of the provision of such
services.
``SEC. 273. STUDENTS; SELECTION; OBLIGATION.
``(a) Student Selection.--
``(1) In general.--Medical, dental, physician assistant,
pharmacy, behavioral and mental health, public health, and
nursing students at the Track shall be selected under
procedures prescribed by the Surgeon General. In so
prescribing, the Surgeon General shall consider the
recommendations of the National Health Care Workforce
Commission.
``(2) Priority.--In developing admissions procedures under
paragraph (1), the Surgeon General shall ensure that such
procedures give priority to applicant medical, dental,
physician assistant, pharmacy, behavioral and mental health,
public health, and nursing students from rural communities
and underrepresented minorities.
``(b) Contract and Service Obligation.--
``(1) Contract.--Upon being admitted to the Track, a
medical, dental, physician assistant, pharmacy, behavioral
and mental health, public health, or nursing student shall
enter into a written contract with the Surgeon General that
shall contain--
``(A) an agreement under which--
``(i) subject to subparagraph (B), the Surgeon General
agrees to provide the student with tuition (or tuition
remission) and a student stipend
[[Page H2055]]
(described in paragraph (2)) in each school year for a period
of years (not to exceed 4 school years) determined by the
student, during which period the student is enrolled in the
Track at an affiliated or other participating health
professions institution pursuant to an agreement between the
Track and such institution; and
``(ii) subject to subparagraph (B), the student agrees--
``(I) to accept the provision of such tuition and student
stipend to the student;
``(II) to maintain enrollment at the Track until the
student completes the course of study involved;
``(III) while enrolled in such course of study, to maintain
an acceptable level of academic standing (as determined by
the Surgeon General);
``(IV) if pursuing a degree from a school of medicine or
osteopathic medicine, dental, public health, or nursing
school or a physician assistant, pharmacy, or behavioral and
mental health professional program, to complete a residency
or internship in a specialty that the Surgeon General
determines is appropriate; and
``(V) to serve for a period of time (referred to in this
part as the `period of obligated service') within the
Commissioned Corps of the Public Health Service equal to 2
years for each school year during which such individual was
enrolled at the College, reduced as provided for in paragraph
(3);
``(B) a provision that any financial obligation of the
United States arising out of a contract entered into under
this part and any obligation of the student which is
conditioned thereon, is contingent upon funds being
appropriated to carry out this part;
``(C) a statement of the damages to which the United States
is entitled for the student's breach of the contract; and
``(D) such other statements of the rights and liabilities
of the Secretary and of the individual, not inconsistent with
the provisions of this part.
``(2) Tuition and student stipend.--
``(A) Tuition remission rates.--The Surgeon General, based
on the recommendations of the National Health Care Workforce
Commission, shall establish Federal tuition remission rates
to be used by the Track to provide reimbursement to
affiliated and other participating health professions
institutions for the cost of educational services provided by
such institutions to Track students. The agreement entered
into by such participating institutions under paragraph
(1)(A)(i) shall contain an agreement to accept as payment in
full the established remission rate under this subparagraph.
``(B) Stipend.--The Surgeon General, based on the
recommendations of the National Health Care Workforce
Commission, shall establish and update Federal stipend rates
for payment to students under this part.
``(3) Reductions in the period of obligated service.--The
period of obligated service under paragraph (1)(A)(ii)(V)
shall be reduced--
``(A) in the case of a student who elects to participate in
a high-needs speciality residency (as determined by the
National Health Care Workforce Commission), by 3 months for
each year of such participation (not to exceed a total of 12
months); and
``(B) in the case of a student who, upon completion of
their residency, elects to practice in a Federal medical
facility (as defined in section 781(e)) that is located in a
health professional shortage area (as defined in section
332), by 3 months for year of full-time practice in such a
facility (not to exceed a total of 12 months).
``(c) Second 2 Years of Service.--During the third and
fourth years in which a medical, dental, physician assistant,
pharmacy, behavioral and mental health, public health, or
nursing student is enrolled in the Track, training should be
designed to prioritize clinical rotations in Federal medical
facilities in health professional shortage areas, and
emphasize a balance of hospital and community-based
experiences, and training within interdisciplinary teams.
``(d) Dentist, Physician Assistant, Pharmacist, Behavioral
and Mental Health Professional, Public Health Professional,
and Nurse Training.--The Surgeon General shall establish
provisions applicable with respect to dental, physician
assistant, pharmacy, behavioral and mental health, public
health, and nursing students that are comparable to those for
medical students under this section, including service
obligations, tuition support, and stipend support. The
Surgeon General shall give priority to health professions
training institutions that train medical, dental, physician
assistant, pharmacy, behavioral and mental health, public
health, and nursing students for some significant period of
time together, but at a minimum have a discrete and shared
core curriculum.
``(e) Elite Federal Disaster Teams.--The Surgeon General,
in consultation with the Secretary, the Director of the
Centers for Disease Control and Prevention, and other
appropriate military and Federal government agencies, shall
develop criteria for the appointment of highly qualified
Track faculty, medical, dental, physician assistant,
pharmacy, behavioral and mental health, public health, and
nursing students, and graduates to elite Federal disaster
preparedness teams to train and to respond to public health
emergencies, natural disasters, bioterrorism events, and
other emergencies.
``(f) Student Dropped From Track in Affiliate School.--A
medical, dental, physician assistant, pharmacy, behavioral
and mental health, public health, or nursing student who,
under regulations prescribed by the Surgeon General, is
dropped from the Track in an affiliated school for deficiency
in conduct or studies, or for other reasons, shall be liable
to the United States for all tuition and stipend support
provided to the student.
``SEC. 274. FUNDING.
``Beginning with fiscal year 2010, the Secretary shall
transfer from the Public Health and Social Services Emergency
Fund such sums as may be necessary to carry out this part.''.
Subtitle E--Supporting the Existing Health Care Workforce
SEC. 5401. CENTERS OF EXCELLENCE.
Section 736 of the Public Health Service Act (42 U.S.C.
293) is amended by striking subsection (h) and inserting the
following:
``(h) Formula for Allocations.--
``(1) Allocations.--Based on the amount appropriated under
subsection (i) for a fiscal year, the following subparagraphs
shall apply as appropriate:
``(A) In general.--If the amounts appropriated under
subsection (i) for a fiscal year are $24,000,000 or less--
``(i) the Secretary shall make available $12,000,000 for
grants under subsection (a) to health professions schools
that meet the conditions described in subsection (c)(2)(A);
and
``(ii) and available after grants are made with funds under
clause (i), the Secretary shall make available--
``(I) 60 percent of such amount for grants under subsection
(a) to health professions schools that meet the conditions
described in paragraph (3) or (4) of subsection (c)
(including meeting the conditions under subsection (e)); and
``(II) 40 percent of such amount for grants under
subsection (a) to health professions schools that meet the
conditions described in subsection (c)(5).
``(B) Funding in excess of $24,000,000.--If amounts
appropriated under subsection (i) for a fiscal year exceed
$24,000,000 but are less than $30,000,000--
``(i) 80 percent of such excess amounts shall be made
available for grants under subsection (a) to health
professions schools that meet the requirements described in
paragraph (3) or (4) of subsection (c) (including meeting
conditions pursuant to subsection (e)); and
``(ii) 20 percent of such excess amount shall be made
available for grants under subsection (a) to health
professions schools that meet the conditions described in
subsection (c)(5).
``(C) Funding in excess of $30,000,000.--If amounts
appropriated under subsection (i) for a fiscal year exceed
$30,000,000 but are less than $40,000,000, the Secretary
shall make available--
``(i) not less than $12,000,000 for grants under subsection
(a) to health professions schools that meet the conditions
described in subsection (c)(2)(A);
``(ii) not less than $12,000,000 for grants under
subsection (a) to health professions schools that meet the
conditions described in paragraph (3) or (4) of subsection
(c) (including meeting conditions pursuant to subsection
(e));
``(iii) not less than $6,000,000 for grants under
subsection (a) to health professions schools that meet the
conditions described in subsection (c)(5); and
``(iv) after grants are made with funds under clauses (i)
through (iii), any remaining excess amount for grants under
subsection (a) to health professions schools that meet the
conditions described in paragraph (2)(A), (3), (4), or (5) of
subsection (c).
``(D) Funding in excess of $40,000,000.--If amounts
appropriated under subsection (i) for a fiscal year are
$40,000,000 or more, the Secretary shall make available--
``(i) not less than $16,000,000 for grants under subsection
(a) to health professions schools that meet the conditions
described in subsection (c)(2)(A);
``(ii) not less than $16,000,000 for grants under
subsection (a) to health professions schools that meet the
conditions described in paragraph (3) or (4) of subsection
(c) (including meeting conditions pursuant to subsection
(e));
``(iii) not less than $8,000,000 for grants under
subsection (a) to health professions schools that meet the
conditions described in subsection (c)(5); and
``(iv) after grants are made with funds under clauses (i)
through (iii), any remaining funds for grants under
subsection (a) to health professions schools that meet the
conditions described in paragraph (2)(A), (3), (4), or (5) of
subsection (c).
``(2) No limitation.--Nothing in this subsection shall be
construed as limiting the centers of excellence referred to
in this section to the designated amount, or to preclude such
entities from competing for grants under this section.
``(3) Maintenance of effort.--
``(A) In general.--With respect to activities for which a
grant made under this part are authorized to be expended, the
Secretary may not make such a grant to a center of excellence
for any fiscal year unless the center agrees to maintain
expenditures of non-Federal amounts for such activities at a
level that is not less than the level of such expenditures
maintained by the center for the fiscal year preceding the
fiscal year for which the school receives such a grant.
``(B) Use of federal funds.--With respect to any Federal
amounts received by a center of excellence and available for
carrying out activities for which a grant under this part is
authorized to be expended, the center shall, before expending
the grant, expend the Federal amounts obtained from sources
other than the grant, unless given prior approval from the
Secretary.
``(i) Authorization of Appropriations.--There are
authorized to be appropriated to carry out this section--
``(1) $50,000,000 for each of the fiscal years 2010 through
2015; and
``(2) and such sums as are necessary for each subsequent
fiscal year.''.
SEC. 5402. HEALTH CARE PROFESSIONALS TRAINING FOR DIVERSITY.
(a) Loan Repayments and Fellowships Regarding Faculty
Positions.--Section 738(a)(1) of the Public Health Service
Act (42 U.S.C. 293b(a)(1)) is amended by striking ``$20,000
of the principal and interest of the educational
[[Page H2056]]
loans of such individuals.'' and inserting ``$30,000 of the
principal and interest of the educational loans of such
individuals.''.
(b) Scholarships for Disadvantaged Students.--Section
740(a) of such Act (42 U.S.C. 293d(a)) is amended by striking
``$37,000,000'' and all that follows through ``2002'' and
inserting ``$51,000,000 for fiscal year 2010, and such sums
as may be necessary for each of the fiscal years 2011 through
2014''.
(c) Reauthorization for Loan Repayments and Fellowships
Regarding Faculty Positions.--Section 740(b) of such Act (42
U.S.C. 293d(b)) is amended by striking ``appropriated'' and
all that follows through the period at the end and inserting
``appropriated, $5,000,000 for each of the fiscal years 2010
through 2014.''.
(d) Reauthorization for Educational Assistance in the
Health Professions Regarding Individuals From a Disadvantaged
Background.--Section 740(c) of such Act (42 U.S.C. 293d(c))
is amended by striking the first sentence and inserting the
following: ``For the purpose of grants and contracts under
section 739(a)(1), there is authorized to be appropriated
$60,000,000 for fiscal year 2010 and such sums as may be
necessary for each of the fiscal years 2011 through 2014.''
SEC. 5403. INTERDISCIPLINARY, COMMUNITY-BASED LINKAGES.
(a) Area Health Education Centers.--Section 751 of the
Public Health Service Act (42 U.S.C. 294a) is amended to read
as follows:
``SEC. 751. AREA HEALTH EDUCATION CENTERS.
``(a) Establishment of Awards.--The Secretary shall make
the following 2 types of awards in accordance with this
section:
``(1) Infrastructure development award.--The Secretary
shall make awards to eligible entities to enable such
entities to initiate health care workforce educational
programs or to continue to carry out comparable programs that
are operating at the time the award is made by planning,
developing, operating, and evaluating an area health
education center program.
``(2) Point of service maintenance and enhancement award.--
The Secretary shall make awards to eligible entities to
maintain and improve the effectiveness and capabilities of an
existing area health education center program, and make other
modifications to the program that are appropriate due to
changes in demographics, needs of the populations served, or
other similar issues affecting the area health education
center program. For the purposes of this section, the term
`Program' refers to the area health education center program.
``(b) Eligible Entities; Application.--
``(1) Eligible entities.--
``(A) Infrastructure development.--For purposes of
subsection (a)(1), the term `eligible entity' means a school
of medicine or osteopathic medicine, an incorporated
consortium of such schools, or the parent institutions of
such a school. With respect to a State in which no area
health education center program is in operation, the
Secretary may award a grant or contract under subsection
(a)(1) to a school of nursing.
``(B) Point of service maintenance and enhancement.--For
purposes of subsection (a)(2), the term `eligible entity'
means an entity that has received funds under this section,
is operating an area health education center program,
including an area health education center or centers, and has
a center or centers that are no longer eligible to receive
financial assistance under subsection (a)(1).
``(2) Application.--An eligible entity desiring to receive
an award under this section shall submit to the Secretary an
application at such time, in such manner, and containing such
information as the Secretary may require.
``(c) Use of Funds.--
``(1) Required activities.--An eligible entity shall use
amounts awarded under a grant under subsection (a)(1) or
(a)(2) to carry out the following activities:
``(A) Develop and implement strategies, in coordination
with the applicable one-stop delivery system under section
134(c) of the Workforce Investment Act of 1998, to recruit
individuals from underrepresented minority populations or
from disadvantaged or rural backgrounds into health
professions, and support such individuals in attaining such
careers.
``(B) Develop and implement strategies to foster and
provide community-based training and education to individuals
seeking careers in health professions within underserved
areas for the purpose of developing and maintaining a diverse
health care workforce that is prepared to deliver high-
quality care, with an emphasis on primary care, in
underserved areas or for health disparity populations, in
collaboration with other Federal and State health care
workforce development programs, the State workforce agency,
and local workforce investment boards, and in health care
safety net sites.
``(C) Prepare individuals to more effectively provide
health services to underserved areas and health disparity
populations through field placements or preceptorships in
conjunction with community-based organizations, accredited
primary care residency training programs, Federally qualified
health centers, rural health clinics, public health
departments, or other appropriate facilities.
``(D) Conduct and participate in interdisciplinary training
that involves physicians, physician assistants, nurse
practitioners, nurse midwives, dentists, psychologists,
pharmacists, optometrists, community health workers, public
and allied health professionals, or other health
professionals, as practicable.
``(E) Deliver or facilitate continuing education and
information dissemination programs for health care
professionals, with an emphasis on individuals providing care
in underserved areas and for health disparity populations.
``(F) Propose and implement effective program and outcomes
measurement and evaluation strategies.
``(G) Establish a youth public health program to expose and
recruit high school students into health careers, with a
focus on careers in public health.
``(2) Innovative opportunities.--An eligible entity may use
amounts awarded under a grant under subsection (a)(1) or
subsection (a)(2) to carry out any of the following
activities:
``(A) Develop and implement innovative curricula in
collaboration with community-based accredited primary care
residency training programs, Federally qualified health
centers, rural health clinics, behavioral and mental health
facilities, public health departments, or other appropriate
facilities, with the goal of increasing the number of primary
care physicians and other primary care providers prepared to
serve in underserved areas and health disparity populations.
``(B) Coordinate community-based participatory research
with academic health centers, and facilitate rapid flow and
dissemination of evidence-based health care information,
research results, and best practices to improve quality,
efficiency, and effectiveness of health care and health care
systems within community settings.
``(C) Develop and implement other strategies to address
identified workforce needs and increase and enhance the
health care workforce in the area served by the area health
education center program.
``(d) Requirements.--
``(1) Area health education center program.--In carrying
out this section, the Secretary shall ensure the following:
``(A) An entity that receives an award under this section
shall conduct at least 10 percent of clinical education
required for medical students in community settings that are
removed from the primary teaching facility of the contracting
institution for grantees that operate a school of medicine or
osteopathic medicine. In States in which an entity that
receives an award under this section is a nursing school or
its parent institution, the Secretary shall alternatively
ensure that--
``(i) the nursing school conducts at least 10 percent of
clinical education required for nursing students in community
settings that are remote from the primary teaching facility
of the school; and
``(ii) the entity receiving the award maintains a written
agreement with a school of medicine or osteopathic medicine
to place students from that school in training sites in the
area health education center program area.
``(B) An entity receiving funds under subsection (a)(2)
does not distribute such funding to a center that is eligible
to receive funding under subsection (a)(1).
``(2) Area health education center.--The Secretary shall
ensure that each area health education center program
includes at least 1 area health education center, and that
each such center--
``(A) is a public or private organization whose structure,
governance, and operation is independent from the awardee and
the parent institution of the awardee;
``(B) is not a school of medicine or osteopathic medicine,
the parent institution of such a school, or a branch campus
or other subunit of a school of medicine or osteopathic
medicine or its parent institution, or a consortium of such
entities;
``(C) designates an underserved area or population to be
served by the center which is in a location removed from the
main location of the teaching facilities of the schools
participating in the program with such center and does not
duplicate, in whole or in part, the geographic area or
population served by any other center;
``(D) fosters networking and collaboration among
communities and between academic health centers and
community-based centers;
``(E) serves communities with a demonstrated need of health
professionals in partnership with academic medical centers;
``(F) addresses the health care workforce needs of the
communities served in coordination with the public workforce
investment system; and
``(G) has a community-based governing or advisory board
that reflects the diversity of the communities involved.
``(e) Matching Funds.--With respect to the costs of
operating a program through a grant under this section, to be
eligible for financial assistance under this section, an
entity shall make available (directly or through
contributions from State, county or municipal governments, or
the private sector) recurring non-Federal contributions in
cash or in kind, toward such costs in an amount that is equal
to not less than 50 percent of such costs. At least 25
percent of the total required non-Federal contributions shall
be in cash. An entity may apply to the Secretary for a waiver
of not more than 75 percent of the matching fund amount
required by the entity for each of the first 3 years the
entity is funded through a grant under subsection (a)(1).
``(f) Limitation.--Not less than 75 percent of the total
amount provided to an area health education center program
under subsection (a)(1) or (a)(2) shall be allocated to the
area health education centers participating in the program
under this section. To provide needed flexibility to newly
funded area health education center programs, the Secretary
may waive the requirement in the sentence for the first 2
years of a new area health education center program funded
under subsection (a)(1).
``(g) Award.--An award to an entity under this section
shall be not less than $250,000 annually per area health
education center included in the program involved. If amounts
appropriated to carry out this section are not sufficient to
comply with the preceding sentence, the Secretary may reduce
the per center amount
[[Page H2057]]
provided for in such sentence as necessary, provided the
distribution established in subsection (j)(2) is maintained.
``(h) Project Terms.--
``(1) In general.--Except as provided in paragraph (2), the
period during which payments may be made under an award under
subsection (a)(1) may not exceed--
``(A) in the case of a program, 12 years; or
``(B) in the case of a center within a program, 6 years.
``(2) Exception.--The periods described in paragraph (1)
shall not apply to programs receiving point of service
maintenance and enhancement awards under subsection (a)(2) to
maintain existing centers and activities.
``(i) Inapplicability of Provision.--Notwithstanding any
other provision of this title, section 791(a) shall not apply
to an area health education center funded under this section.
``(j) Authorization of Appropriations.--
``(1) In general.--There is authorized to be appropriated
to carry out this section $125,000,000 for each of the fiscal
years 2010 through 2014.
``(2) Requirements.--Of the amounts appropriated for a
fiscal year under paragraph (1)--
``(A) not more than 35 percent shall be used for awards
under subsection (a)(1);
``(B) not less than 60 percent shall be used for awards
under subsection (a)(2);
``(C) not more than 1 percent shall be used for grants and
contracts to implement outcomes evaluation for the area
health education centers; and
``(D) not more than 4 percent shall be used for grants and
contracts to provide technical assistance to entities
receiving awards under this section.
``(3) Carryover funds.--An entity that receives an award
under this section may carry over funds from 1 fiscal year to
another without obtaining approval from the Secretary. In no
case may any funds be carried over pursuant to the preceding
sentence for more than 3 years.
``(k) Sense of Congress.--It is the sense of the Congress
that every State have an area health education center program
in effect under this section.''.
(b) Continuing Educational Support for Health Professionals
Serving in Underserved Communities.--Part D of title VII of
the Public Health Service Act (42 U.S.C. 294 et seq.) is
amended by striking section 752 and inserting the following:
``SEC. 752. CONTINUING EDUCATIONAL SUPPORT FOR HEALTH
PROFESSIONALS SERVING IN UNDERSERVED
COMMUNITIES.
``(a) In General.--The Secretary shall make grants to, and
enter into contracts with, eligible entities to improve
health care, increase retention, increase representation of
minority faculty members, enhance the practice environment,
and provide information dissemination and educational support
to reduce professional isolation through the timely
dissemination of research findings using relevant resources.
``(b) Eligible Entities.--For purposes of this section, the
term `eligible entity' means an entity described in section
799(b).
``(c) Application.--An eligible entity desiring to receive
an award under this section shall submit to the Secretary an
application at such time, in such manner, and containing such
information as the Secretary may require.
``(d) Use of Funds.--An eligible entity shall use amounts
awarded under a grant or contract under this section to
provide innovative supportive activities to enhance education
through distance learning, continuing educational activities,
collaborative conferences, and electronic and telelearning
activities, with priority for primary care.
``(e) Authorization.--There is authorized to be
appropriated to carry out this section $5,000,000 for each of
the fiscal years 2010 through 2014, and such sums as may be
necessary for each subsequent fiscal year.''.
SEC. 5404. WORKFORCE DIVERSITY GRANTS.
Section 821 of the Public Health Service Act (42 U.S.C.
296m) is amended--
(1) in subsection (a)--
(A) by striking ``The Secretary may'' and inserting the
following:
``(1) Authority.--The Secretary may'';
(B) by striking ``pre-entry preparation, and retention
activities'' and inserting the following: ``stipends for
diploma or associate degree nurses to enter a bridge or
degree completion program, student scholarships or stipends
for accelerated nursing degree programs, pre-entry
preparation, advanced education preparation, and retention
activities''; and
(2) in subsection (b)--
(A) by striking ``First'' and all that follows through
``including the'' and inserting ``National Advisory Council
on Nurse Education and Practice and consult with nursing
associations including the National Coalition of Ethnic
Minority Nurse Associations,''; and
(B) by inserting before the period the following: ``, and
other organizations determined appropriate by the
Secretary''.
SEC. 5405. PRIMARY CARE EXTENSION PROGRAM.
Part P of title III of the Public Health Service Act (42
U.S.C. 280g et seq.), as amended by section 5313, is further
amended by adding at the end the following:
``SEC. 399W. PRIMARY CARE EXTENSION PROGRAM.
``(a) Establishment, Purpose and Definition.--
``(1) In general.--The Secretary, acting through the
Director of the Agency for Healthcare Research and Quality,
shall establish a Primary Care Extension Program.
``(2) Purpose.--The Primary Care Extension Program shall
provide support and assistance to primary care providers to
educate providers about preventive medicine, health
promotion, chronic disease management, mental and behavioral
health services (including substance abuse prevention and
treatment services), and evidence-based and evidence-informed
therapies and techniques, in order to enable providers to
incorporate such matters into their practice and to improve
community health by working with community-based health
connectors (referred to in this section as `Health Extension
Agents').
``(3) Definitions.--In this section:
``(A) Health extension agent.--The term `Health Extension
Agent' means any local, community-based health worker who
facilitates and provides assistance to primary care practices
by implementing quality improvement or system redesign,
incorporating the principles of the patient-centered medical
home to provide high-quality, effective, efficient, and safe
primary care and to provide guidance to patients in
culturally and linguistically appropriate ways, and linking
practices to diverse health system resources.
``(B) Primary care provider.--The term `primary care
provider' means a clinician who provides integrated,
accessible health care services and who is accountable for
addressing a large majority of personal health care needs,
including providing preventive and health promotion services
for men, women, and children of all ages, developing a
sustained partnership with patients, and practicing in the
context of family and community, as recognized by a State
licensing or regulatory authority, unless otherwise specified
in this section.
``(b) Grants To Establish State Hubs and Local Primary Care
Extension Agencies.--
``(1) Grants.--The Secretary shall award competitive grants
to States for the establishment of State- or multistate-level
primary care Primary Care Extension Program State Hubs
(referred to in this section as `Hubs').
``(2) Composition of hubs.--A Hub established by a State
pursuant to paragraph (1)--
``(A) shall consist of, at a minimum, the State health
department, the entity responsible for administering the
State Medicaid program (if other than the State health
department), the State-level entity administering the
Medicare program, and the departments of 1 or more health
professions schools in the State that train providers in
primary care; and
``(B) may include entities such as hospital associations,
primary care practice-based research networks, health
professional societies, State primary care associations,
State licensing boards, organizations with a contract with
the Secretary under section 1153 of the Social Security Act,
consumer groups, and other appropriate entities.
``(c) State and Local Activities.--
``(1) Hub activities.--Hubs established under a grant under
subsection (b) shall--
``(A) submit to the Secretary a plan to coordinate
functions with quality improvement organizations and area
health education centers if such entities are members of the
Hub not described in subsection (b)(2)(A);
``(B) contract with a county- or local-level entity that
shall serve as the Primary Care Extension Agency to
administer the services described in paragraph (2);
``(C) organize and administer grant funds to county- or
local-level Primary Care Extension Agencies that serve a
catchment area, as determined by the State; and
``(D) organize State-wide or multistate networks of local-
level Primary Care Extension Agencies to share and
disseminate information and practices.
``(2) Local primary care extension agency activities.--
``(A) Required activities.--Primary Care Extension Agencies
established by a Hub under paragraph (1) shall--
``(i) assist primary care providers to implement a patient-
centered medical home to improve the accessibility, quality,
and efficiency of primary care services, including health
homes;
``(ii) develop and support primary care learning
communities to enhance the dissemination of research findings
for evidence-based practice, assess implementation of
practice improvement, share best practices, and involve
community clinicians in the generation of new knowledge and
identification of important questions for research;
``(iii) participate in a national network of Primary Care
Extension Hubs and propose how the Primary Care Extension
Agency will share and disseminate lessons learned and best
practices; and
``(iv) develop a plan for financial sustainability
involving State, local, and private contributions, to provide
for the reduction in Federal funds that is expected after an
initial 6-year period of program establishment,
infrastructure development, and planning.
``(B) Discretionary activities.--Primary Care Extension
Agencies established by a Hub under paragraph (1) may--
``(i) provide technical assistance, training, and
organizational support for community health teams established
under section 3602 of the Patient Protection and Affordable
Care Act;
``(ii) collect data and provision of primary care provider
feedback from standardized measurements of processes and
outcomes to aid in continuous performance improvement;
``(iii) collaborate with local health departments,
community health centers, tribes and tribal entities, and
other community agencies to identify community health
priorities and local health workforce needs, and participate
in community-based efforts to address the social and primary
determinants of health, strengthen the local primary care
workforce, and eliminate health disparities;
``(iv) develop measures to monitor the impact of the
proposed program on the health of practice enrollees and of
the wider community served; and
``(v) participate in other activities, as determined
appropriate by the Secretary.
[[Page H2058]]
``(d) Federal Program Administration.--
``(1) Grants; types.--Grants awarded under subsection (b)
shall be--
``(A) program grants, that are awarded to State or
multistate entities that submit fully-developed plans for the
implementation of a Hub, for a period of 6 years; or
``(B) planning grants, that are awarded to State or
multistate entities with the goal of developing a plan for a
Hub, for a period of 2 years.
``(2) Applications.--To be eligible for a grant under
subsection (b), a State or multistate entity shall submit to
the Secretary an application, at such time, in such manner,
and containing such information as the Secretary may require.
``(3) Evaluation.--A State that receives a grant under
subsection (b) shall be evaluated at the end of the grant
period by an evaluation panel appointed by the Secretary.
``(4) Continuing support.--After the sixth year in which
assistance is provided to a State under a grant awarded under
subsection (b), the State may receive additional support
under this section if the State program has received
satisfactory evaluations with respect to program performance
and the merits of the State sustainability plan, as
determined by the Secretary.
``(5) Limitation.--A State shall not use in excess of 10
percent of the amount received under a grant to carry out
administrative activities under this section. Funds awarded
pursuant to this section shall not be used for funding direct
patient care.
``(e) Requirements on the Secretary.--In carrying out this
section, the Secretary shall consult with the heads of other
Federal agencies with demonstrated experience and expertise
in health care and preventive medicine, such as the Centers
for Disease Control and Prevention, the Substance Abuse and
Mental Health Administration, the Health Resources and
Services Administration, the National Institutes of Health,
the Office of the National Coordinator for Health Information
Technology, the Indian Health Service, the Agricultural
Cooperative Extension Service of the Department of
Agriculture, and other entities, as the Secretary determines
appropriate.
``(f) Authorization of Appropriations.--To awards grants as
provided in subsection (d), there are authorized to be
appropriated $120,000,000 for each of fiscal years 2011 and
2012, and such sums as may be necessary to carry out this
section for each of fiscal years 2013 through 2014.''.
Subtitle F--Strengthening Primary Care and Other Workforce Improvements
SEC. 5501. EXPANDING ACCESS TO PRIMARY CARE SERVICES AND
GENERAL SURGERY SERVICES.
(a) Incentive Payment Program for Primary Care Services.--
(1) In general.--Section 1833 of the Social Security Act
(42 U.S.C. 1395l) is amended by adding at the end the
following new subsection:
``(x) Incentive Payments for Primary Care Services.--
``(1) In general.--In the case of primary care services
furnished on or after January 1, 2011, and before January 1,
2016, by a primary care practitioner, in addition to the
amount of payment that would otherwise be made for such
services under this part, there also shall be paid (on a
monthly or quarterly basis) an amount equal to 10 percent of
the payment amount for the service under this part.
``(2) Definitions.--In this subsection:
``(A) Primary care practitioner.--The term `primary care
practitioner' means an individual--
``(i) who--
``(I) is a physician (as described in section 1861(r)(1))
who has a primary specialty designation of family medicine,
internal medicine, geriatric medicine, or pediatric medicine;
or
``(II) is a nurse practitioner, clinical nurse specialist,
or physician assistant (as those terms are defined in section
1861(aa)(5)); and
``(ii) for whom primary care services accounted for at
least 60 percent of the allowed charges under this part for
such physician or practitioner in a prior period as
determined appropriate by the Secretary.
``(B) Primary care services.--The term `primary care
services' means services identified, as of January 1, 2009,
by the following HCPCS codes (and as subsequently modified by
the Secretary):
``(i) 99201 through 99215.
``(ii) 99304 through 99340.
``(iii) 99341 through 99350.
``(3) Coordination with other payments.--The amount of the
additional payment for a service under this subsection and
subsection (m) shall be determined without regard to any
additional payment for the service under subsection (m) and
this subsection, respectively.
``(4) Limitation on review.--There shall be no
administrative or judicial review under section 1869, 1878,
or otherwise, respecting the identification of primary care
practitioners under this subsection.''.
(2) Conforming amendment.--Section 1834(g)(2)(B) of the
Social Security Act (42 U.S.C. 1395m(g)(2)(B)) is amended by
adding at the end the following sentence: ``Section 1833(x)
shall not be taken into account in determining the amounts
that would otherwise be paid pursuant to the preceding
sentence.''.
(b) Incentive Payment Program for Major Surgical Procedures
Furnished in Health Professional Shortage Areas.--
(1) In general.--Section 1833 of the Social Security Act
(42 U.S.C. 1395l), as amended by subsection (a)(1), is
amended by adding at the end the following new subsection:
``(y) Incentive Payments for Major Surgical Procedures
Furnished in Health Professional Shortage Areas.--
``(1) In general.--In the case of major surgical procedures
furnished on or after January 1, 2011, and before January 1,
2016, by a general surgeon in an area that is designated
(under section 332(a)(1)(A) of the Public Health Service Act)
as a health professional shortage area as identified by the
Secretary prior to the beginning of the year involved, in
addition to the amount of payment that would otherwise be
made for such services under this part, there also shall be
paid (on a monthly or quarterly basis) an amount equal to 10
percent of the payment amount for the service under this
part.
``(2) Definitions.--In this subsection:
``(A) General surgeon.--In this subsection, the term
`general surgeon' means a physician (as described in section
1861(r)(1)) who has designated CMS specialty code 02-General
Surgery as their primary specialty code in the physician's
enrollment under section 1866(j).
``(B) Major surgical procedures.--The term `major surgical
procedures' means physicians' services which are surgical
procedures for which a 10-day or 90-day global period is used
for payment under the fee schedule under section 1848(b).
``(3) Coordination with other payments.--The amount of the
additional payment for a service under this subsection and
subsection (m) shall be determined without regard to any
additional payment for the service under subsection (m) and
this subsection, respectively.
``(4) Application.--The provisions of paragraph (2) and (4)
of subsection (m) shall apply to the determination of
additional payments under this subsection in the same manner
as such provisions apply to the determination of additional
payments under subsection (m).''.
(2) Conforming amendment.--Section 1834(g)(2)(B) of the
Social Security Act (42 U.S.C. 1395m(g)(2)(B)), as amended by
subsection (a)(2), is amended by striking ``Section 1833(x)''
and inserting ``Subsections (x) and (y) of section 1833'' in
the last sentence.
(c) Budget-neutrality Adjustment.--Section 1848(c)(2)(B) of
the Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)) is
amended by adding at the end the following new clause:
``(vii) Adjustment for certain physician incentive
payments.--Fifty percent of the additional expenditures under
this part attributable to subsections (x) and (y) of section
1833 for a year (as estimated by the Secretary) shall be
taken into account in applying clause (ii)(II) for 2011 and
subsequent years. In lieu of applying the budget-neutrality
adjustments required under clause (ii)(II) to relative value
units to account for such costs for the year, the Secretary
shall apply such budget-neutrality adjustments to the
conversion factor otherwise determined for the year. For 2011
and subsequent years, the Secretary shall increase the
incentive payment otherwise applicable under section 1833(m)
by a percent estimated to be equal to the additional
expenditures estimated under the first sentence of this
clause for such year that is applicable to physicians who
primarily furnish services in areas designated (under section
332(a)(1)(A) of the Public Health Service Act) as health
professional shortage areas.''.
SEC. 5502. MEDICARE FEDERALLY QUALIFIED HEALTH CENTER
IMPROVEMENTS.
(a) Expansion of Medicare-Covered Preventive Services at
Federally Qualified Health Centers.--
(1) In general.--Section 1861(aa)(3)(A) of the Social
Security Act (42 U.S.C. 1395w (aa)(3)(A)) is amended to read
as follows:
``(A) services of the type described subparagraphs (A)
through (C) of paragraph (1) and preventive services (as
defined in section 1861(ddd)(3)); and''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to services furnished on or after January 1,
2011.
(b) Prospective Payment System for Federally Qualified
Health Centers.--Section 1834 of the Social Security Act (42
U.S.C. 1395m) is amended by adding at the end the following
new subsection:
``(n) Development and Implementation of Prospective Payment
System.--
``(1) Development.--
``(A) In general.--The Secretary shall develop a
prospective payment system for payment for Federally
qualified health services furnished by Federally qualified
health centers under this title. Such system shall include a
process for appropriately describing the services furnished
by Federally qualified health centers.
``(B) Collection of data and evaluation.--The Secretary
shall require Federally qualified health centers to submit to
the Secretary such information as the Secretary may require
in order to develop and implement the prospective payment
system under this paragraph and paragraph (2), respectively,
including the reporting of services using HCPCS codes.
``(2) Implementation.--
``(A) In general.--Notwithstanding section 1833(a)(3)(B),
the Secretary shall provide, for cost reporting periods
beginning on or after October 1, 2014, for payments for
Federally qualified health services furnished by Federally
qualified health centers under this title in accordance with
the prospective payment system developed by the Secretary
under paragraph (1).
``(B) Payments.--
``(i) Initial payments.--The Secretary shall implement such
prospective payment system so that the estimated amount of
expenditures under this title for Federally qualified health
services in the first year that the prospective payment
system is implemented is equal to 103 percent of the
estimated amount of expenditures under this title that would
have occurred for such services in such year if the system
had not been implemented.
``(ii) Payments in subsequent years.--In the year after the
first year of implementation of such system, and in each
subsequent year, the payment rate for Federally qualified
health services furnished in the year shall be equal to the
payment rate established for such services furnished in the
preceding year under this subparagraph increased by the
percentage increase
[[Page H2059]]
in the MEI (as defined in 1842(i)(3)) for the year
involved.''.
SEC. 5503. DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS.
(a) In General.--Section 1886(h) of the Social Security Act
(42 U.S.C. 1395ww(h)) is amended--
(1) in paragraph (4)(F)(i), by striking ``paragraph (7)''
and inserting ``paragraphs (7) and (8)'';
(2) in paragraph (4)(H)(i), by striking ``paragraph (7)''
and inserting ``paragraphs (7) and (8)'';
(3) in paragraph (7)(E), by inserting ``or paragraph (8)''
before the period at the end; and
(4) by adding at the end the following new paragraph:
``(8) Distribution of additional residency positions.--
``(A) Reductions in limit based on unused positions.--
``(i) In general.--Except as provided in clause (ii), if a
hospital's reference resident level (as defined in
subparagraph (H)(i)) is less than the otherwise applicable
resident limit (as defined in subparagraph (H)(iii)),
effective for portions of cost reporting periods occurring on
or after July 1, 2011, the otherwise applicable resident
limit shall be reduced by 65 percent of the difference
between such otherwise applicable resident limit and such
reference resident level.
``(ii) Exceptions.--This subparagraph shall not apply to--
``(I) a hospital located in a rural area (as defined in
subsection (d)(2)(D)(ii)) with fewer than 250 acute care
inpatient beds;
``(II) a hospital that was part of a qualifying entity
which had a voluntary residency reduction plan approved under
paragraph (6)(B) or under the authority of section 402 of
Public Law 90-248, if the hospital demonstrates to the
Secretary that it has a specified plan in place for filling
the unused positions by not later than 2 years after the date
of enactment of this paragraph; or
``(III) a hospital described in paragraph (4)(H)(v).
``(B) Distribution.--
``(i) In general.--The Secretary shall increase the
otherwise applicable resident limit for each qualifying
hospital that submits an application under this subparagraph
by such number as the Secretary may approve for portions of
cost reporting periods occurring on or after July 1, 2011.
The aggregate number of increases in the otherwise applicable
resident limit under this subparagraph shall be equal to the
aggregate reduction in such limits attributable to
subparagraph (A) (as estimated by the Secretary).
``(ii) Requirements.--Subject to clause (iii), a hospital
that receives an increase in the otherwise applicable
resident limit under this subparagraph shall ensure, during
the 5-year period beginning on the date of such increase,
that--
``(I) the number of full-time equivalent primary care
residents, as defined in paragraph (5)(H) (as determined by
the Secretary), excluding any additional positions under
subclause (II), is not less than the average number of full-
time equivalent primary care residents (as so determined)
during the 3 most recent cost reporting periods ending prior
to the date of enactment of this paragraph; and
``(II) not less than 75 percent of the positions
attributable to such increase are in a primary care or
general surgery residency (as determined by the Secretary).
The Secretary may determine whether a hospital has met the
requirements under this clause during such 5-year period in
such manner and at such time as the Secretary determines
appropriate, including at the end of such 5-year period.
``(iii) Redistribution of positions if hospital no longer
meets certain requirements.--In the case where the Secretary
determines that a hospital described in clause (ii) does not
meet either of the requirements under subclause (I) or (II)
of such clause, the Secretary shall--
``(I) reduce the otherwise applicable resident limit of the
hospital by the amount by which such limit was increased
under this paragraph; and
``(II) provide for the distribution of positions
attributable to such reduction in accordance with the
requirements of this paragraph.
``(C) Considerations in redistribution.--In determining for
which hospitals the increase in the otherwise applicable
resident limit is provided under subparagraph (B), the
Secretary shall take into account--
``(i) the demonstration likelihood of the hospital filling
the positions made available under this paragraph within the
first 3 cost reporting periods beginning on or after July 1,
2011, as determined by the Secretary; and
``(ii) whether the hospital has an accredited rural
training track (as described in paragraph (4)(H)(iv)).
``(D) Priority for certain areas.--In determining for which
hospitals the increase in the otherwise applicable resident
limit is provided under subparagraph (B), subject to
subparagraph (E), the Secretary shall distribute the increase
to hospitals based on the following factors:
``(i) Whether the hospital is located in a State with a
resident-to-population ratio in the lowest quartile (as
determined by the Secretary).
``(ii) Whether the hospital is located in a State, a
territory of the United States, or the District of Columbia
that is among the top 10 States, territories, or Districts in
terms of the ratio of--
``(I) the total population of the State, territory, or
District living in an area designated (under such section
332(a)(1)(A)) as a health professional shortage area (as of
the date of enactment of this paragraph); to
``(II) the total population of the State, territory, or
District (as determined by the Secretary based on the most
recent available population data published by the Bureau of
the Census).
``(iii) Whether the hospital is located in a rural area (as
defined in subsection (d)(2)(D)(ii)).
``(E) Reservation of positions for certain hospitals.--
``(i) In general.--Subject to clause (ii), the Secretary
shall reserve the positions available for distribution under
this paragraph as follows:
``(I) 70 percent of such positions for distribution to
hospitals described in clause (i) of subparagraph (D).
``(II) 30 percent of such positions for distribution to
hospitals described in clause (ii) and (iii) of such
subparagraph.
``(ii) Exception if positions not redistributed by july 1,
2011.--In the case where the Secretary does not distribute
positions to hospitals in accordance with clause (i) by July
1, 2011, the Secretary shall distribute such positions to
other hospitals in accordance with the considerations
described in subparagraph (C) and the priority described in
subparagraph (D).
``(F) Limitation.--A hospital may not receive more than 75
full-time equivalent additional residency positions under
this paragraph.
``(G) Application of per resident amounts for primary care
and nonprimary care.--With respect to additional residency
positions in a hospital attributable to the increase provided
under this paragraph, the approved FTE per resident amounts
are deemed to be equal to the hospital per resident amounts
for primary care and nonprimary care computed under paragraph
(2)(D) for that hospital.
``(H) Definitions.--In this paragraph:
``(i) Reference resident level.--The term `reference
resident level' means, with respect to a hospital, the
highest resident level for any of the 3 most recent cost
reporting periods (ending before the date of the enactment of
this paragraph) of the hospital for which a cost report has
been settled (or, if not, submitted (subject to audit)), as
determined by the Secretary.
``(ii) Resident level.--The term `resident level' has the
meaning given such term in paragraph (7)(C)(i).
``(iii) Otherwise applicable resident limit.--The term
`otherwise applicable resident limit' means, with respect to
a hospital, the limit otherwise applicable under
subparagraphs (F)(i) and (H) of paragraph (4) on the resident
level for the hospital determined without regard to this
paragraph but taking into account paragraph (7)(A).''.
(b) IME.--
(1) In general.--Section 1886(d)(5)(B)(v) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second
sentence, is amended--
(A) by striking ``subsection (h)(7)'' and inserting
``subsections (h)(7) and (h)(8)''; and
(B) by striking ``it applies'' and inserting ``they
apply''.
(2) Conforming amendment.--Section 1886(d)(5)(B) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by
adding at the end the following clause:
``(x) For discharges occurring on or after July 1, 2011,
insofar as an additional payment amount under this
subparagraph is attributable to resident positions
distributed to a hospital under subsection (h)(8)(B), the
indirect teaching adjustment factor shall be computed in the
same manner as provided under clause (ii) with respect to
such resident positions.''.
(c) Conforming Amendment.--Section 422(b)(2) of the
Medicare Prescription Drug, Improvement, and Modernization
Act of 2003 (Public Law 108-173) is amended by striking
``section 1886(h)(7)'' and all that follows and inserting
``paragraphs (7) and (8) of subsection (h) of section 1886 of
the Social Security Act''.
SEC. 5504. COUNTING RESIDENT TIME IN NONPROVIDER SETTINGS.
(a) GME.--Section 1886(h)(4)(E) of the Social Security Act
(42 U.S.C. 1395ww(h)(4)(E)) is amended--
(1) by striking ``shall be counted and that all the time''
and inserting ``shall be counted and that--
``(i) effective for cost reporting periods beginning before
July 1, 2010, all the time;'';
(2) in clause (i), as inserted by paragraph (1), by
striking the period at the end and inserting ``; and'';
(3) by inserting after clause (i), as so inserted, the
following new clause:
``(ii) effective for cost reporting periods beginning on or
after July 1, 2010, all the time so spent by a resident shall
be counted towards the determination of full-time
equivalency, without regard to the setting in which the
activities are performed, if a hospital incurs the costs of
the stipends and fringe benefits of the resident during the
time the resident spends in that setting. If more than one
hospital incurs these costs, either directly or through a
third party, such hospitals shall count a proportional share
of the time, as determined by written agreement between the
hospitals, that a resident spends training in that
setting.''; and
(4) by adding at the end the following flush sentence:
``Any hospital claiming under this subparagraph for time
spent in a nonprovider setting shall maintain and make
available to the Secretary records regarding the amount of
such time and such amount in comparison with amounts of such
time in such base year as the Secretary shall specify.''.
(b) IME.--Section 1886(d)(5)(B)(iv) of the Social Security
Act (42 U.S.C. 1395ww(d)(5)) is amended--
(1) by striking ``(iv) Effective for discharges occurring
on or after October 1, 1997'' and inserting ``(iv)(I)
Effective for discharges occurring on or after October 1,
1997, and before July 1, 2010''; and
[[Page H2060]]
(2) by inserting after clause (I), as inserted by paragraph
(1), the following new subparagraph:
``(II) Effective for discharges occurring on or after July
1, 2010, all the time spent by an intern or resident in
patient care activities in a nonprovider setting shall be
counted towards the determination of full-time equivalency if
a hospital incurs the costs of the stipends and fringe
benefits of the intern or resident during the time the intern
or resident spends in that setting. If more than one hospital
incurs these costs, either directly or through a third party,
such hospitals shall count a proportional share of the time,
as determined by written agreement between the hospitals,
that a resident spends training in that setting.''.
(c) Application.--The amendments made by this section shall
not be applied in a manner that requires reopening of any
settled hospital cost reports as to which there is not a
jurisdictionally proper appeal pending as of the date of the
enactment of this Act on the issue of payment for indirect
costs of medical education under section 1886(d)(5)(B) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct
graduate medical education costs under section 1886(h) of
such Act (42 U.S.C. 1395ww(h)).
SEC. 5505. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC AND
SCHOLARLY ACTIVITIES AND OTHER ACTIVITIES.
(a) GME.--Section 1886(h) of the Social Security Act (42
U.S.C. 1395ww(h)), as amended by section 5504, is amended--
(1) in paragraph (4)--
(A) in subparagraph (E), by striking ``Such rules'' and
inserting ``Subject to subparagraphs (J) and (K), such
rules''; and
(B) by adding at the end the following new subparagraphs:
``(J) Treatment of certain nonprovider and didactic
activities.--Such rules shall provide that all time spent by
an intern or resident in an approved medical residency
training program in a nonprovider setting that is primarily
engaged in furnishing patient care (as defined in paragraph
(5)(K)) in non-patient care activities, such as didactic
conferences and seminars, but not including research not
associated with the treatment or diagnosis of a particular
patient, as such time and activities are defined by the
Secretary, shall be counted toward the determination of full-
time equivalency.
``(K) Treatment of certain other activities.--In
determining the hospital's number of full-time equivalent
residents for purposes of this subsection, all the time that
is spent by an intern or resident in an approved medical
residency training program on vacation, sick leave, or other
approved leave, as such time is defined by the Secretary, and
that does not prolong the total time the resident is
participating in the approved program beyond the normal
duration of the program shall be counted toward the
determination of full-time equivalency.''; and
(2) in paragraph (5), by adding at the end the following
new subparagraph:
``(K) Nonprovider setting that is primarily engaged in
furnishing patient care.--The term `nonprovider setting that
is primarily engaged in furnishing patient care' means a
nonprovider setting in which the primary activity is the care
and treatment of patients, as defined by the Secretary.''.
(b) IME Determinations.--Section 1886(d)(5)(B) of such Act
(42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end
the following new clause:
``(x)(I) The provisions of subparagraph (K) of subsection
(h)(4) shall apply under this subparagraph in the same manner
as they apply under such subsection.
``(II) In determining the hospital's number of full-time
equivalent residents for purposes of this subparagraph, all
the time spent by an intern or resident in an approved
medical residency training program in non-patient care
activities, such as didactic conferences and seminars, as
such time and activities are defined by the Secretary, that
occurs in the hospital shall be counted toward the
determination of full-time equivalency if the hospital--
``(aa) is recognized as a subsection (d) hospital;
``(bb) is recognized as a subsection (d) Puerto Rico
hospital;
``(cc) is reimbursed under a reimbursement system
authorized under section 1814(b)(3); or
``(dd) is a provider-based hospital outpatient department.
``(III) In determining the hospital's number of full-time
equivalent residents for purposes of this subparagraph, all
the time spent by an intern or resident in an approved
medical residency training program in research activities
that are not associated with the treatment or diagnosis of a
particular patient, as such time and activities are defined
by the Secretary, shall not be counted toward the
determination of full-time equivalency.''.
(c) Effective Dates.--
(1) In general.--Except as otherwise provided, the
Secretary of Health and Human Services shall implement the
amendments made by this section in a manner so as to apply to
cost reporting periods beginning on or after January 1, 1983.
(2) GME.--Section 1886(h)(4)(J) of the Social Security Act,
as added by subsection (a)(1)(B), shall apply to cost
reporting periods beginning on or after July 1, 2009.
(3) IME.--Section 1886(d)(5)(B)(x)(III) of the Social
Security Act, as added by subsection (b), shall apply to cost
reporting periods beginning on or after October 1, 2001. Such
section, as so added, shall not give rise to any inference as
to how the law in effect prior to such date should be
interpreted.
SEC. 5506. PRESERVATION OF RESIDENT CAP POSITIONS FROM CLOSED
HOSPITALS.
(a) GME.--Section 1886(h)(4)(H) of the Social Security Act
(42 U.S.C. Section 1395ww(h)(4)(H)) is amended by adding at
the end the following new clause:
``(vi) Redistribution of residency slots after a hospital
closes.--
``(I) In general.--Subject to the succeeding provisions of
this clause, the Secretary shall, by regulation, establish a
process under which, in the case where a hospital (other than
a hospital described in clause (v)) with an approved medical
residency program closes on or after a date that is 2 years
before the date of enactment of this clause, the Secretary
shall increase the otherwise applicable resident limit under
this paragraph for other hospitals in accordance with this
clause.
``(II) Priority for hospitals in certain areas.--Subject to
the succeeding provisions of this clause, in determining for
which hospitals the increase in the otherwise applicable
resident limit is provided under such process, the Secretary
shall distribute the increase to hospitals in the following
priority order (with preference given within each category to
hospitals that are members of the same affiliated group (as
defined by the Secretary under clause (ii)) as the closed
hospital):
``(aa) First, to hospitals located in the same core-based
statistical area as, or a core-based statistical area
contiguous to, the hospital that closed.
``(bb) Second, to hospitals located in the same State as
the hospital that closed.
``(cc) Third, to hospitals located in the same region of
the country as the hospital that closed.
``(dd) Fourth, only if the Secretary is not able to
distribute the increase to hospitals described in item (cc),
to qualifying hospitals in accordance with the provisions of
paragraph (8).
``(III) Requirement hospital likely to fill position within
certain time period.--The Secretary may only increase the
otherwise applicable resident limit of a hospital under such
process if the Secretary determines the hospital has
demonstrated a likelihood of filling the positions made
available under this clause within 3 years.
``(IV) Limitation.--The aggregate number of increases in
the otherwise applicable resident limits for hospitals under
this clause shall be equal to the number of resident
positions in the approved medical residency programs that
closed on or after the date described in subclause (I).
``(V) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to the implementation of this
clause.''.
(b) IME.--Section 1886(d)(5)(B)(v) of the Social Security
Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second sentence,
as amended by section 5503, is amended by striking
``subsections (h)(7) and (h)(8)'' and inserting ``subsections
(h)(4)(H)(vi), (h)(7), and (h)(8)''.
(c) Application.--The amendments made by this section shall
not be applied in a manner that requires reopening of any
settled hospital cost reports as to which there is not a
jurisdictionally proper appeal pending as of the date of the
enactment of this Act on the issue of payment for indirect
costs of medical education under section 1886(d)(5)(B) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct
graduate medical education costs under section 1886(h) of
such Act (42 U.S.C. Section 1395ww(h)).
(d) Effect on Temporary FTE Cap Adjustments.--The Secretary
of Health and Human Services shall give consideration to the
effect of the amendments made by this section on any
temporary adjustment to a hospital's FTE cap under section
413.79(h) of title 42, Code of Federal Regulations (as in
effect on the date of enactment of this Act) in order to
ensure that there is no duplication of FTE slots. Such
amendments shall not affect the application of section
1886(h)(4)(H)(v) of the Social Security Act (42 U.S.C.
1395ww(h)(4)(H)(v)).
(e) Conforming Amendment.--Section 1886(h)(7)(E) of the
Social Security Act (42 U.S.C. 1395ww(h)(7)(E)), as amended
by section 5503(a), is amended by striking ``paragraph or
paragraph (8)'' and inserting ``this paragraph, paragraph
(8), or paragraph (4)(H)(vi)''.
SEC. 5507. DEMONSTRATION PROJECTS TO ADDRESS HEALTH
PROFESSIONS WORKFORCE NEEDS; EXTENSION OF
FAMILY-TO-FAMILY HEALTH INFORMATION CENTERS.
(a) Authority To Conduct Demonstration Projects.--Title XX
of the Social Security Act (42 U.S.C. 1397 et seq.) is
amended by adding at the end the following:
``SEC. 2008. DEMONSTRATION PROJECTS TO ADDRESS HEALTH
PROFESSIONS WORKFORCE NEEDS.
``(a) Demonstration Projects To Provide Low-Income
Individuals With Opportunities for Education, Training, and
Career Advancement To Address Health Professions Workforce
Needs.--
``(1) Authority to award grants.--The Secretary, in
consultation with the Secretary of Labor, shall award grants
to eligible entities to conduct demonstration projects that
are designed to provide eligible individuals with the
opportunity to obtain education and training for occupations
in the health care field that pay well and are expected to
either experience labor shortages or be in high demand.
``(2) Requirements.--
``(A) Aid and supportive services.--
``(i) In general.--A demonstration project conducted by an
eligible entity awarded a grant under this section shall, if
appropriate, provide eligible individuals participating in
the project with financial aid, child care, case management,
and other supportive services.
``(ii) Treatment.--Any aid, services, or incentives
provided to an eligible beneficiary participating in a
demonstration project under this section shall not be
considered income, and shall not be taken into account for
purposes of determining the individual's eligibility for, or
amount of, benefits under any means-tested program.
[[Page H2061]]
``(B) Consultation and coordination.--An eligible entity
applying for a grant to carry out a demonstration project
under this section shall demonstrate in the application that
the entity has consulted with the State agency responsible
for administering the State TANF program, the local workforce
investment board in the area in which the project is to be
conducted (unless the applicant is such board), the State
workforce investment board established under section 111 of
the Workforce Investment Act of 1998, and the State
Apprenticeship Agency recognized under the Act of August 16,
1937 (commonly known as the `National Apprenticeship Act')
(or if no agency has been recognized in the State, the Office
of Apprenticeship of the Department of Labor) and that the
project will be carried out in coordination with such
entities.
``(C) Assurance of opportunities for indian populations.--
The Secretary shall award at least 3 grants under this
subsection to an eligible entity that is an Indian tribe,
tribal organization, or Tribal College or University.
``(3) Reports and evaluation.--
``(A) Eligible entities.--An eligible entity awarded a
grant to conduct a demonstration project under this
subsection shall submit interim reports to the Secretary on
the activities carried out under the project and a final
report on such activities upon the conclusion of the
entities' participation in the project. Such reports shall
include assessments of the effectiveness of such activities
with respect to improving outcomes for the eligible
individuals participating in the project and with respect to
addressing health professions workforce needs in the areas in
which the project is conducted.
``(B) Evaluation.--The Secretary shall, by grant, contract,
or interagency agreement, evaluate the demonstration projects
conducted under this subsection. Such evaluation shall
include identification of successful activities for creating
opportunities for developing and sustaining, particularly
with respect to low-income individuals and other entry-level
workers, a health professions workforce that has accessible
entry points, that meets high standards for education,
training, certification, and professional development, and
that provides increased wages and affordable benefits,
including health care coverage, that are responsive to the
workforce's needs.
``(C) Report to congress.--The Secretary shall submit
interim reports and, based on the evaluation conducted under
subparagraph (B), a final report to Congress on the
demonstration projects conducted under this subsection.
``(4) Definitions.--In this subsection:
``(A) Eligible entity.--The term `eligible entity' means a
State, an Indian tribe or tribal organization, an institution
of higher education, a local workforce investment board
established under section 117 of the Workforce Investment Act
of 1998, a sponsor of an apprenticeship program registered
under the National Apprenticeship Act or a community-based
organization.
``(B) Eligible individual.--
``(i) In general.--The term `eligible individual' means a
individual receiving assistance under the State TANF program.
``(ii) Other low-income individuals.--Such term may include
other low-income individuals described by the eligible entity
in its application for a grant under this section.
``(C) Indian tribe; tribal organization.--The terms `Indian
tribe' and `tribal organization' have the meaning given such
terms in section 4 of the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450b).
``(D) Institution of higher education.--The term
`institution of higher education' has the meaning given that
term in section 101 of the Higher Education Act of 1965 (20
U.S.C. 1001).
``(E) State.--The term `State' means each of the 50 States,
the District of Columbia, the Commonwealth of Puerto Rico,
the United States Virgin Islands, Guam, and American Samoa.
``(F) State tanf program.--The term `State TANF program'
means the temporary assistance for needy families program
funded under part A of title IV.
``(G) Tribal college or university.--The term `Tribal
College or University' has the meaning given that term in
section 316(b) of the Higher Education Act of 1965 (20 U.S.C.
1059c(b)).
``(b) Demonstration Project To Develop Training and
Certification Programs for Personal or Home Care Aides.--
``(1) Authority to award grants.--Not later than 18 months
after the date of enactment of this section, the Secretary
shall award grants to eligible entities that are States to
conduct demonstration projects for purposes of developing
core training competencies and certification programs for
personal or home care aides. The Secretary shall--
``(A) evaluate the efficacy of the core training
competencies described in paragraph (3)(A) for newly hired
personal or home care aides and the methods used by States to
implement such core training competencies in accordance with
the issues specified in paragraph (3)(B); and
``(B) ensure that the number of hours of training provided
by States under the demonstration project with respect to
such core training competencies are not less than the number
of hours of training required under any applicable State or
Federal law or regulation.
``(2) Duration.--A demonstration project shall be conducted
under this subsection for not less than 3 years.
``(3) Core training competencies for personal or home care
aides.--
``(A) In general.--The core training competencies for
personal or home care aides described in this subparagraph
include competencies with respect to the following areas:
``(i) The role of the personal or home care aide (including
differences between a personal or home care aide employed by
an agency and a personal or home care aide employed directly
by the health care consumer or an independent provider).
``(ii) Consumer rights, ethics, and confidentiality
(including the role of proxy decision-makers in the case
where a health care consumer has impaired decision-making
capacity).
``(iii) Communication, cultural and linguistic competence
and sensitivity, problem solving, behavior management, and
relationship skills.
``(iv) Personal care skills.
``(v) Health care support.
``(vi) Nutritional support.
``(vii) Infection control.
``(viii) Safety and emergency training.
``(ix) Training specific to an individual consumer's needs
(including older individuals, younger individuals with
disabilities, individuals with developmental disabilities,
individuals with dementia, and individuals with mental and
behavioral health needs).
``(x) Self-Care.
``(B) Implementation.--The implementation issues specified
in this subparagraph include the following:
``(i) The length of the training.
``(ii) The appropriate trainer to student ratio.
``(iii) The amount of instruction time spent in the
classroom as compared to on-site in the home or a facility.
``(iv) Trainer qualifications.
``(v) Content for a `hands-on' and written certification
exam.
``(vi) Continuing education requirements.
``(4) Application and selection criteria.--
``(A) In general.--
``(i) Number of states.--The Secretary shall enter into
agreements with not more than 6 States to conduct
demonstration projects under this subsection.
``(ii) Requirements for states.--An agreement entered into
under clause (i) shall require that a participating State--
``(I) implement the core training competencies described in
paragraph (3)(A); and
``(II) develop written materials and protocols for such
core training competencies, including the development of a
certification test for personal or home care aides who have
completed such training competencies.
``(iii) Consultation and collaboration with community and
vocational colleges.--The Secretary shall encourage
participating States to consult with community and vocational
colleges regarding the development of curricula to implement
the project with respect to activities, as applicable, which
may include consideration of such colleges as partners in
such implementation.
``(B) Application and eligibility.--A State seeking to
participate in the project shall--
``(i) submit an application to the Secretary containing
such information and at such time as the Secretary may
specify;
``(ii) meet the selection criteria established under
subparagraph (C); and
``(iii) meet such additional criteria as the Secretary may
specify.
``(C) Selection criteria.--In selecting States to
participate in the program, the Secretary shall establish
criteria to ensure (if applicable with respect to the
activities involved)--
``(i) geographic and demographic diversity;
``(ii) that participating States offer medical assistance
for personal care services under the State Medicaid plan;
``(iii) that the existing training standards for personal
or home care aides in each participating State--
``(I) are different from such standards in the other
participating States; and
``(II) are different from the core training competencies
described in paragraph (3)(A);
``(iv) that participating States do not reduce the number
of hours of training required under applicable State law or
regulation after being selected to participate in the
project; and
``(v) that participating States recruit a minimum number of
eligible health and long-term care providers to participate
in the project.
``(D) Technical assistance.--The Secretary shall provide
technical assistance to States in developing written
materials and protocols for such core training competencies.
``(5) Evaluation and report.--
``(A) Evaluation.--The Secretary shall develop an
experimental or control group testing protocol in
consultation with an independent evaluation contractor
selected by the Secretary. Such contractor shall evaluate--
``(i) the impact of core training competencies described in
paragraph (3)(A), including curricula developed to implement
such core training competencies, for personal or home care
aides within each participating State on job satisfaction,
mastery of job skills, beneficiary and family caregiver
satisfaction with services, and additional measures
determined by the Secretary in consultation with the expert
panel;
``(ii) the impact of providing such core training
competencies on the existing training infrastructure and
resources of States; and
``(iii) whether a minimum number of hours of initial
training should be required for personal or home care aides
and, if so, what minimum number of hours should be required.
``(B) Reports.--
``(i) Report on initial implementation.--Not later than 2
years after the date of enactment of this section, the
Secretary shall submit to Congress a report on the initial
implementation of activities conducted under the
demonstration project, including any available results of the
evaluation conducted under subparagraph (A) with respect to
such activities, together with such recommendations for
legislation or administrative action as the Secretary
determines appropriate.
``(ii) Final report.--Not later than 1 year after the
completion of the demonstration project, the Secretary shall
submit to Congress a report containing the results of the
evaluation conducted under subparagraph (A), together with
such recommendations for legislation or administrative action
as the Secretary determines appropriate.
[[Page H2062]]
``(6) Definitions.--In this subsection:
``(A) Eligible health and long-term care provider.--The
term `eligible health and long-term care provider' means a
personal or home care agency (including personal or home care
public authorities), a nursing home, a home health agency (as
defined in section 1861(o)), or any other health care
provider the Secretary determines appropriate which--
``(i) is licensed or authorized to provide services in a
participating State; and
``(ii) receives payment for services under title XIX.
``(B) Personal care services.--The term `personal care
services' has the meaning given such term for purposes of
title XIX.
``(C) Personal or home care aide.--The term `personal or
home care aide' means an individual who helps individuals who
are elderly, disabled, ill, or mentally disabled (including
an individual with Alzheimer's disease or other dementia) to
live in their own home or a residential care facility (such
as a nursing home, assisted living facility, or any other
facility the Secretary determines appropriate) by providing
routine personal care services and other appropriate services
to the individual.
``(D) State.--The term `State' has the meaning given that
term for purposes of title XIX.
``(c) Funding.--
``(1) In general.--Subject to paragraph (2), out of any
funds in the Treasury not otherwise appropriated, there are
appropriated to the Secretary to carry out subsections (a)
and (b), $85,000,000 for each of fiscal years 2010 through
2014.
``(2) Training and certification programs for personal and
home care aides.--With respect to the demonstration projects
under subsection (b), the Secretary shall use $5,000,000 of
the amount appropriated under paragraph (1) for each of
fiscal years 2010 through 2012 to carry out such projects. No
funds appropriated under paragraph (1) shall be used to carry
out demonstration projects under subsection (b) after fiscal
year 2012.
``(d) Nonapplication.--
``(1) In general.--Except as provided in paragraph (2), the
preceding sections of this title shall not apply to grant
awarded under this section.
``(2) Limitations on use of grants.--Section 2005(a) (other
than paragraph (6)) shall apply to a grant awarded under this
section to the same extent and in the same manner as such
section applies to payments to States under this title.''.
(b) Extension of Family-To-Family Health Information
Centers.--Section 501(c)(1)(A)(iii) of the Social Security
Act (42 U.S.C. 701(c)(1)(A)(iii)) is amended by striking
``fiscal year 2009'' and inserting ``each of fiscal years
2009 through 2012''.
SEC. 5508. INCREASING TEACHING CAPACITY.
(a) Teaching Health Centers Training and Enhancement.--Part
C of title VII of the Public Health Service Act (42 U.S.C.
293k et. seq.), as amended by section 5303, is further
amended by inserting after section 749 the following:
``SEC. 749A. TEACHING HEALTH CENTERS DEVELOPMENT GRANTS.
``(a) Program Authorized.--The Secretary may award grants
under this section to teaching health centers for the purpose
of establishing new accredited or expanded primary care
residency programs.
``(b) Amount and Duration.--Grants awarded under this
section shall be for a term of not more than 3 years and the
maximum award may not be more than $500,000.
``(c) Use of Funds.--Amounts provided under a grant under
this section shall be used to cover the costs of--
``(1) establishing or expanding a primary care residency
training program described in subsection (a), including costs
associated with--
``(A) curriculum development;
``(B) recruitment, training and retention of residents and
faculty:
``(C) accreditation by the Accreditation Council for
Graduate Medical Education (ACGME), the American Dental
Association (ADA), or the American Osteopathic Association
(AOA); and
``(D) faculty salaries during the development phase; and
``(2) technical assistance provided by an eligible entity.
``(d) Application.--A teaching health center seeking a
grant under this section shall submit an application to the
Secretary at such time, in such manner, and containing such
information as the Secretary may require.
``(e) Preference for Certain Applications.--In selecting
recipients for grants under this section, the Secretary shall
give preference to any such application that documents an
existing affiliation agreement with an area health education
center program as defined in sections 751 and 799B.
``(f) Definitions.--In this section:
``(1) Eligible entity.--The term `eligible entity' means an
organization capable of providing technical assistance
including an area health education center program as defined
in sections 751 and 799B.
``(2) Primary care residency program.--The term `primary
care residency program' means an approved graduate medical
residency training program (as defined in section 340H) in
family medicine, internal medicine, pediatrics, internal
medicine-pediatrics, obstetrics and gynecology, psychiatry,
general dentistry, pediatric dentistry, and geriatrics.
``(3) Teaching health center.--
``(A) In general.--The term `teaching health center' means
an entity that--
``(i) is a community based, ambulatory patient care center;
and
``(ii) operates a primary care residency program.
``(B) Inclusion of certain entities.--Such term includes
the following:
``(i) A Federally qualified health center (as defined in
section 1905(l)(2)(B), of the Social Security Act).
``(ii) A community mental health center (as defined in
section 1861(ff)(3)(B) of the Social Security Act).
``(iii) A rural health clinic, as defined in section
1861(aa) of the Social Security Act.
``(iv) A health center operated by the Indian Health
Service, an Indian tribe or tribal organization, or an urban
Indian organization (as defined in section 4 of the Indian
Health Care Improvement Act).
``(v) An entity receiving funds under title X of the Public
Health Service Act.
``(g) Authorization of Appropriations.--There is authorized
to be appropriated, $25,000,000 for fiscal year 2010,
$50,000,000 for fiscal year 2011, $50,000,000 for fiscal year
2012, and such sums as may be necessary for each fiscal year
thereafter to carry out this section. Not to exceed
$5,000,000 annually may be used for technical assistance
program grants.''.
(b) National Health Service Corps Teaching Capacity.--
Section 338C(a) of the Public Health Service Act (42 U.S.C.
254m(a)) is amended to read as follows:
``(a) Service in Full-time Clinical Practice.--Except as
provided in section 338D, each individual who has entered
into a written contract with the Secretary under section 338A
or 338B shall provide service in the full-time clinical
practice of such individual's profession as a member of the
Corps for the period of obligated service provided in such
contract. For the purpose of calculating time spent in full-
time clinical practice under this subsection, up to 50
percent of time spent teaching by a member of the Corps may
be counted toward his or her service obligation.''.
(c) Payments to Qualified Teaching Health Centers.--Part D
of title III of the Public Health Service Act (42 U.S.C. 254b
et seq.) is amended by adding at the end the following:
``Subpart XI--Support of Graduate Medical Education in Qualified
Teaching Health Centers
``SEC. 340H. PROGRAM OF PAYMENTS TO TEACHING HEALTH CENTERS
THAT OPERATE GRADUATE MEDICAL EDUCATION
PROGRAMS.
``(a) Payments.--Subject to subsection (h)(2), the
Secretary shall make payments under this section for direct
expenses and for indirect expenses to qualified teaching
health centers that are listed as sponsoring institutions by
the relevant accrediting body for expansion of existing or
establishment of new approved graduate medical residency
training programs.
``(b) Amount of Payments.--
``(1) In general.--Subject to paragraph (2), the amounts
payable under this section to qualified teaching health
centers for an approved graduate medical residency training
program for a fiscal year are each of the following amounts:
``(A) Direct expense amount.--The amount determined under
subsection (c) for direct expenses associated with sponsoring
approved graduate medical residency training programs.
``(B) Indirect expense amount.--The amount determined under
subsection (d) for indirect expenses associated with the
additional costs relating to teaching residents in such
programs.
``(2) Capped amount.--
``(A) In general.--The total of the payments made to
qualified teaching health centers under paragraph (1)(A) or
paragraph (1)(B) in a fiscal year shall not exceed the amount
of funds appropriated under subsection (g) for such payments
for that fiscal year.
``(B) Limitation.--The Secretary shall limit the funding of
full-time equivalent residents in order to ensure the direct
and indirect payments as determined under subsection (c) and
(d) do not exceed the total amount of funds appropriated in a
fiscal year under subsection (g).
``(c) Amount of Payment for Direct Graduate Medical
Education.--
``(1) In general.--The amount determined under this
subsection for payments to qualified teaching health centers
for direct graduate expenses relating to approved graduate
medical residency training programs for a fiscal year is
equal to the product of--
``(A) the updated national per resident amount for direct
graduate medical education, as determined under paragraph
(2); and
``(B) the average number of full-time equivalent residents
in the teaching health center's graduate approved medical
residency training programs as determined under section
1886(h)(4) of the Social Security Act (without regard to the
limitation under subparagraph (F) of such section) during the
fiscal year.
``(2) Updated national per resident amount for direct
graduate medical education.--The updated per resident amount
for direct graduate medical education for a qualified
teaching health center for a fiscal year is an amount
determined as follows:
``(A) Determination of qualified teaching health center per
resident amount.--The Secretary shall compute for each
individual qualified teaching health center a per resident
amount--
``(i) by dividing the national average per resident amount
computed under section 340E(c)(2)(D) into a wage-related
portion and a non-wage related portion by applying the
proportion determined under subparagraph (B);
``(ii) by multiplying the wage-related portion by the
factor applied under section 1886(d)(3)(E) of the Social
Security Act (but without application of section 4410 of the
Balanced Budget Act of 1997 (42 U.S.C. 1395ww note)) during
the preceding fiscal year for the teaching health center's
area; and
``(iii) by adding the non-wage-related portion to the
amount computed under clause (ii).
``(B) Updating rate.--The Secretary shall update such per
resident amount for each such
[[Page H2063]]
qualified teaching health center as determined appropriate by
the Secretary.
``(d) Amount of Payment for Indirect Medical Education.--
``(1) In general.--The amount determined under this
subsection for payments to qualified teaching health centers
for indirect expenses associated with the additional costs of
teaching residents for a fiscal year is equal to an amount
determined appropriate by the Secretary.
``(2) Factors.--In determining the amount under paragraph
(1), the Secretary shall--
``(A) evaluate indirect training costs relative to
supporting a primary care residency program in qualified
teaching health centers; and
``(B) based on this evaluation, assure that the aggregate
of the payments for indirect expenses under this section and
the payments for direct graduate medical education as
determined under subsection (c) in a fiscal year do not
exceed the amount appropriated for such expenses as
determined in subsection (g).
``(3) Interim payment.--Before the Secretary makes a
payment under this subsection pursuant to a determination of
indirect expenses under paragraph (1), the Secretary may
provide to qualified teaching health centers a payment, in
addition to any payment made under subsection (c), for
expected indirect expenses associated with the additional
costs of teaching residents for a fiscal year, based on an
estimate by the Secretary.
``(e) Clarification Regarding Relationship to Other
Payments for Graduate Medical Education.--Payments under this
section--
``(1) shall be in addition to any payments--
``(A) for the indirect costs of medical education under
section 1886(d)(5)(B) of the Social Security Act;
``(B) for direct graduate medical education costs under
section 1886(h) of such Act; and
``(C) for direct costs of medical education under section
1886(k) of such Act;
``(2) shall not be taken into account in applying the
limitation on the number of total full-time equivalent
residents under subparagraphs (F) and (G) of section
1886(h)(4) of such Act and clauses (v), (vi)(I), and (vi)(II)
of section 1886(d)(5)(B) of such Act for the portion of time
that a resident rotates to a hospital; and
``(3) shall not include the time in which a resident is
counted toward full-time equivalency by a hospital under
paragraph (2) or under section 1886(d)(5)(B)(iv) of the
Social Security Act, section 1886(h)(4)(E) of such Act, or
section 340E of this Act.
``(f) Reconciliation.--The Secretary shall determine any
changes to the number of residents reported by a hospital in
the application of the hospital for the current fiscal year
to determine the final amount payable to the hospital for the
current fiscal year for both direct expense and indirect
expense amounts. Based on such determination, the Secretary
shall recoup any overpayments made to pay any balance due to
the extent possible. The final amount so determined shall be
considered a final intermediary determination for the
purposes of section 1878 of the Social Security Act and shall
be subject to administrative and judicial review under that
section in the same manner as the amount of payment under
section 1186(d) of such Act is subject to review under such
section.
``(g) Funding.--To carry out this section, there are
appropriated such sums as may be necessary, not to exceed
$230,000,000, for the period of fiscal years 2011 through
2015.
``(h) Annual Reporting Required.--
``(1) Annual report.--The report required under this
paragraph for a qualified teaching health center for a fiscal
year is a report that includes (in a form and manner
specified by the Secretary) the following information for the
residency academic year completed immediately prior to such
fiscal year:
``(A) The types of primary care resident approved training
programs that the qualified teaching health center provided
for residents.
``(B) The number of approved training positions for
residents described in paragraph (4).
``(C) The number of residents described in paragraph (4)
who completed their residency training at the end of such
residency academic year and care for vulnerable populations
living in underserved areas.
``(D) Other information as deemed appropriate by the
Secretary.
``(2) Audit authority; limitation on payment.--
``(A) Audit authority.--The Secretary may audit a qualified
teaching health center to ensure the accuracy and
completeness of the information submitted in a report under
paragraph (1).
``(B) Limitation on payment.--A teaching health center may
only receive payment in a cost reporting period for a number
of such resident positions that is greater than the base
level of primary care resident positions, as determined by
the Secretary. For purposes of this subparagraph, the `base
level of primary care residents' for a teaching health center
is the level of such residents as of a base period.
``(3) Reduction in payment for failure to report.--
``(A) In general.--The amount payable under this section to
a qualified teaching health center for a fiscal year shall be
reduced by at least 25 percent if the Secretary determines
that--
``(i) the qualified teaching health center has failed to
provide the Secretary, as an addendum to the qualified
teaching health center's application under this section for
such fiscal year, the report required under paragraph (1) for
the previous fiscal year; or
``(ii) such report fails to provide complete and accurate
information required under any subparagraph of such
paragraph.
``(B) Notice and opportunity to provide accurate and
missing information.--Before imposing a reduction under
subparagraph (A) on the basis of a qualified teaching health
center's failure to provide complete and accurate information
described in subparagraph (A)(ii), the Secretary shall
provide notice to the teaching health center of such failure
and the Secretary's intention to impose such reduction and
shall provide the teaching health center with the opportunity
to provide the required information within the period of 30
days beginning on the date of such notice. If the teaching
health center provides such information within such period,
no reduction shall be made under subparagraph (A) on the
basis of the previous failure to provide such information.
``(4) Residents.--The residents described in this paragraph
are those who are in part-time or full-time equivalent
resident training positions at a qualified teaching health
center in any approved graduate medical residency training
program.
``(i) Regulations.--The Secretary shall promulgate
regulations to carry out this section.
``(j) Definitions.--In this section:
``(1) Approved graduate medical residency training
program.--The term `approved graduate medical residency
training program' means a residency or other postgraduate
medical training program--
``(A) participation in which may be counted toward
certification in a specialty or subspecialty and includes
formal postgraduate training programs in geriatric medicine
approved by the Secretary; and
``(B) that meets criteria for accreditation (as established
by the Accreditation Council for Graduate Medical Education,
the American Osteopathic Association, or the American Dental
Association).
``(2) Primary care residency program.--The term `primary
care residency program' has the meaning given that term in
section 749A.
``(3) Qualified teaching health center.--The term
`qualified teaching health center' has the meaning given the
term `teaching health center' in section 749A.''.
SEC. 5509. GRADUATE NURSE EDUCATION DEMONSTRATION.
(a) In General.--
(1) Establishment.--
(A) In general.--The Secretary shall establish a graduate
nurse education demonstration under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.) under which an eligible
hospital may receive payment for the hospital's reasonable
costs (described in paragraph (2)) for the provision of
qualified clinical training to advance practice nurses.
(B) Number.--The demonstration shall include up to 5
eligible hospitals.
(C) Written agreements.--Eligible hospitals selected to
participate in the demonstration shall enter into written
agreements pursuant to subsection (b) in order to reimburse
the eligible partners of the hospital the share of the costs
attributable to each partner.
(2) Costs described.--
(A) In general.--Subject to subparagraph (B) and subsection
(d), the costs described in this paragraph are the reasonable
costs (as described in section 1861(v) of the Social Security
Act (42 U.S.C. 1395x(v))) of each eligible hospital for the
clinical training costs (as determined by the Secretary) that
are attributable to providing advanced practice registered
nurses with qualified training.
(B) Limitation.--With respect to a year, the amount
reimbursed under subparagraph (A) may not exceed the amount
of costs described in subparagraph (A) that are attributable
to an increase in the number of advanced practice registered
nurses enrolled in a program that provides qualified training
during the year and for which the hospital is being
reimbursed under the demonstration, as compared to the
average number of advanced practice registered nurses who
graduated in each year during the period beginning on January
1, 2006, and ending on December 31, 2010 (as determined by
the Secretary) from the graduate nursing education program
operated by the applicable school of nursing that is an
eligible partner of the hospital for purposes of the
demonstration.
(3) Waiver authority.--The Secretary may waive such
requirements of titles XI and XVIII of the Social Security
Act as may be necessary to carry out the demonstration.
(4) Administration.--Chapter 35 of title 44, United States
Code, shall not apply to the implementation of this section.
(b) Written Agreements With Eligible Partners.--No payment
shall be made under this section to an eligible hospital
unless such hospital has in effect a written agreement with
the eligible partners of the hospital. Such written agreement
shall describe, at a minimum--
(1) the obligations of the eligible partners with respect
to the provision of qualified training; and
(2) the obligation of the eligible hospital to reimburse
such eligible partners applicable (in a timely manner) for
the costs of such qualified training attributable to partner.
(c) Evaluation.--Not later than October 17, 2017, the
Secretary shall submit to Congress a report on the
demonstration. Such report shall include an analysis of the
following:
(1) The growth in the number of advanced practice
registered nurses with respect to a specific base year as a
result of the demonstration.
(2) The growth for each of the specialties described in
subparagraphs (A) through (D) of subsection (e)(1).
(3) The costs to the Medicare program under title XVIII of
the Social Security Act as a result of the demonstration.
(4) Other items the Secretary determines appropriate and
relevant.
(d) Funding.--
(1) In general.--There is hereby appropriated to the
Secretary, out of any funds in the Treasury not otherwise
appropriated, $50,000,000 for each of fiscal years 2012
through 2015 to carry out this section, including the design,
implementation, monitoring, and evaluation of the
demonstration.
[[Page H2064]]
(2) Proration.--If the aggregate payments to eligible
hospitals under the demonstration exceed $50,000,000 for a
fiscal year described in paragraph (1), the Secretary shall
prorate the payment amounts to each eligible hospital in
order to ensure that the aggregate payments do not exceed
such amount.
(3) Without fiscal year limitation.--Amounts appropriated
under this subsection shall remain available without fiscal
year limitation.
(e) Definitions.--In this section:
(1) Advanced practice registered nurse.--The term
``advanced practice registered nurse'' includes the
following:
(A) A clinical nurse specialist (as defined in subsection
(aa)(5) of section 1861 of the Social Security Act (42 U.S.C.
1395x)).
(B) A nurse practitioner (as defined in such subsection).
(C) A certified registered nurse anesthetist (as defined in
subsection (bb)(2) of such section).
(D) A certified nurse-midwife (as defined in subsection
(gg)(2) of such section).
(2) Applicable non-hospital community-based care setting.--
The term ``applicable non-hospital community-based care
setting'' means a non-hospital community-based care setting
which has entered into a written agreement (as described in
subsection (b)) with the eligible hospital participating in
the demonstration. Such settings include Federally qualified
health centers, rural health clinics, and other non-hospital
settings as determined appropriate by the Secretary.
(3) Applicable school of nursing.--The term ``applicable
school of nursing'' means an accredited school of nursing (as
defined in section 801 of the Public Health Service Act)
which has entered into a written agreement (as described in
subsection (b)) with the eligible hospital participating in
the demonstration.
(4) Demonstration.--The term ``demonstration'' means the
graduate nurse education demonstration established under
subsection (a).
(5) Eligible hospital.--The term ``eligible hospital''
means a hospital (as defined in subsection (e) of section
1861 of the Social Security Act (42 U.S.C. 1395x)) or a
critical access hospital (as defined in subsection (mm)(1) of
such section) that has a written agreement in place with--
(A) 1 or more applicable schools of nursing; and
(B) 2 or more applicable non-hospital community-based care
settings.
(6) Eligible partners.--The term ``eligible partners''
includes the following:
(A) An applicable non-hospital community-based care
setting.
(B) An applicable school of nursing.
(7) Qualified training.--
(A) In general.--The term ``qualified training'' means
training--
(i) that provides an advanced practice registered nurse
with the clinical skills necessary to provide primary care,
preventive care, transitional care, chronic care management,
and other services appropriate for individuals entitled to,
or enrolled for, benefits under part A of title XVIII of the
Social Security Act, or enrolled under part B of such title;
and
(ii) subject to subparagraph (B), at least half of which is
provided in a non-hospital community-based care setting.
(B) Waiver of requirement half of training be provided in
non-hospital community-based care setting in certain areas.--
The Secretary may waive the requirement under subparagraph
(A)(ii) with respect to eligible hospitals located in rural
or medically underserved areas.
(8) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
Subtitle G--Improving Access to Health Care Services
SEC. 5601. SPENDING FOR FEDERALLY QUALIFIED HEALTH CENTERS
(FQHCS).
(a) In General.--Section 330(r) of the Public Health
Service Act (42 U.S.C. 254b(r)) is amended by striking
paragraph (1) and inserting the following:
``(1) General amounts for grants.--For the purpose of
carrying out this section, in addition to the amounts
authorized to be appropriated under subsection (d), there is
authorized to be appropriated the following:
``(A) For fiscal year 2010, $2,988,821,592.
``(B) For fiscal year 2011, $3,862,107,440.
``(C) For fiscal year 2012, $4,990,553,440.
``(D) For fiscal year 2013, $6,448,713,307.
``(E) For fiscal year 2014, $7,332,924,155.
``(F) For fiscal year 2015, $8,332,924,155.
``(G) For fiscal year 2016, and each subsequent fiscal
year, the amount appropriated for the preceding fiscal year
adjusted by the product of--
``(i) one plus the average percentage increase in costs
incurred per patient served; and
``(ii) one plus the average percentage increase in the
total number of patients served.''.
(b) Rule of Construction.--Section 330(r) of the Public
Health Service Act (42 U.S.C. 254b(r)) is amended by adding
at the end the following:
``(4) Rule of construction with respect to rural health
clinics.--
``(A) In general.--Nothing in this section shall be
construed to prevent a community health center from
contracting with a Federally certified rural health clinic
(as defined in section 1861(aa)(2) of the Social Security
Act), a low-volume hospital (as defined for purposes of
section 1886 of such Act), a critical access hospital, a sole
community hospital (as defined for purposes of section
1886(d)(5)(D)(iii) of such Act), or a medicare-dependent
share hospital (as defined for purposes of section
1886(d)(5)(G)(iv) of such Act) for the delivery of primary
health care services that are available at the clinic or
hospital to individuals who would otherwise be eligible for
free or reduced cost care if that individual were able to
obtain that care at the community health center. Such
services may be limited in scope to those primary health care
services available in that clinic or hospitals.
``(B) Assurances.--In order for a clinic or hospital to
receive funds under this section through a contract with a
community health center under subparagraph (A), such clinic
or hospital shall establish policies to ensure--
``(i) nondiscrimination based on the ability of a patient
to pay; and
``(ii) the establishment of a sliding fee scale for low-
income patients.''.
SEC. 5602. NEGOTIATED RULEMAKING FOR DEVELOPMENT OF
METHODOLOGY AND CRITERIA FOR DESIGNATING
MEDICALLY UNDERSERVED POPULATIONS AND HEALTH
PROFESSIONS SHORTAGE AREAS.
(a) Establishment.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
establish, through a negotiated rulemaking process under
subchapter 3 of chapter 5 of title 5, United States Code, a
comprehensive methodology and criteria for designation of--
(A) medically underserved populations in accordance with
section 330(b)(3) of the Public Health Service Act (42 U.S.C.
254b(b)(3));
(B) health professions shortage areas under section 332 of
the Public Health Service Act (42 U.S.C. 254e).
(2) Factors to consider.--In establishing the methodology
and criteria under paragraph (1), the Secretary--
(A) shall consult with relevant stakeholders who will be
significantly affected by a rule (such as national, State and
regional organizations representing affected entities), State
health offices, community organizations, health centers and
other affected entities, and other interested parties; and
(B) shall take into account--
(i) the timely availability and appropriateness of data
used to determine a designation to potential applicants for
such designations;
(ii) the impact of the methodology and criteria on
communities of various types and on health centers and other
safety net providers;
(iii) the degree of ease or difficulty that will face
potential applicants for such designations in securing the
necessary data; and
(iv) the extent to which the methodology accurately
measures various barriers that confront individuals and
population groups in seeking health care services.
(b) Publication of Notice.--In carrying out the rulemaking
process under this subsection, the Secretary shall publish
the notice provided for under section 564(a) of title 5,
United States Code, by not later than 45 days after the date
of the enactment of this Act.
(c) Target Date for Publication of Rule.--As part of the
notice under subsection (b), and for purposes of this
subsection, the ``target date for publication'', as referred
to in section 564(a)(5) of title 5, United Sates Code, shall
be July 1, 2010.
(d) Appointment of Negotiated Rulemaking Committee and
Facilitator.--The Secretary shall provide for--
(1) the appointment of a negotiated rulemaking committee
under section 565(a) of title 5, United States Code, by not
later than 30 days after the end of the comment period
provided for under section 564(c) of such title; and
(2) the nomination of a facilitator under section 566(c) of
such title 5 by not later than 10 days after the date of
appointment of the committee.
(e) Preliminary Committee Report.--The negotiated
rulemaking committee appointed under subsection (d) shall
report to the Secretary, by not later than April 1, 2010,
regarding the committee's progress on achieving a consensus
with regard to the rulemaking proceeding and whether such
consensus is likely to occur before one month before the
target date for publication of the rule. If the committee
reports that the committee has failed to make significant
progress toward such consensus or is unlikely to reach such
consensus by the target date, the Secretary may terminate
such process and provide for the publication of a rule under
this section through such other methods as the Secretary may
provide.
(f) Final Committee Report.--If the committee is not
terminated under subsection (e), the rulemaking committee
shall submit a report containing a proposed rule by not later
than one month before the target publication date.
(g) Interim Final Effect.--The Secretary shall publish a
rule under this section in the Federal Register by not later
than the target publication date. Such rule shall be
effective and final immediately on an interim basis, but is
subject to change and revision after public notice and
opportunity for a period (of not less than 90 days) for
public comment. In connection with such rule, the Secretary
shall specify the process for the timely review and approval
of applications for such designations pursuant to such rules
and consistent with this section.
(h) Publication of Rule After Public Comment.--The
Secretary shall provide for consideration of such comments
and republication of such rule by not later than 1 year after
the target publication date.
SEC. 5603. REAUTHORIZATION OF THE WAKEFIELD EMERGENCY MEDICAL
SERVICES FOR CHILDREN PROGRAM.
Section 1910 of the Public Health Service Act (42 U.S.C.
300w-9) is amended--
(1) in subsection (a), by striking ``3-year period (with an
optional 4th year'' and inserting ``4-year period (with an
optional 5th year''; and
(2) in subsection (d)--
(A) by striking ``and such sums'' and inserting ``such
sums''; and
(B) by inserting before the period the following: ``,
$25,000,000 for fiscal year 2010, $26,250,000 for fiscal year
2011, $27,562,500 for fiscal year 2012, $28,940,625 for
fiscal year 2013, and $30,387,656 for fiscal year 2014''.
[[Page H2065]]
SEC. 5604. CO-LOCATING PRIMARY AND SPECIALTY CARE IN
COMMUNITY-BASED MENTAL HEALTH SETTINGS.
Subpart 3 of part B of title V of the Public Health Service
Act (42 U.S.C. 290bb-31 et seq.) is amended by adding at the
end the following:
``SEC. 520K. AWARDS FOR CO-LOCATING PRIMARY AND SPECIALTY
CARE IN COMMUNITY-BASED MENTAL HEALTH SETTINGS.
``(a) Definitions.--In this section:
``(1) Eligible entity.--The term `eligible entity' means a
qualified community mental health program defined under
section 1913(b)(1).
``(2) Special populations.--The term `special populations'
means adults with mental illnesses who have co-occurring
primary care conditions and chronic diseases.
``(b) Program Authorized.--The Secretary, acting through
the Administrator shall award grants and cooperative
agreements to eligible entities to establish demonstration
projects for the provision of coordinated and integrated
services to special populations through the co-location of
primary and specialty care services in community-based mental
and behavioral health settings.
``(c) Application.--To be eligible to receive a grant or
cooperative agreement under this section, an eligible entity
shall submit an application to the Administrator at such
time, in such manner, and accompanied by such information as
the Administrator may require, including a description of
partnerships, or other arrangements with local primary care
providers, including community health centers, to provide
services to special populations.
``(d) Use of Funds.--
``(1) In general.--For the benefit of special populations,
an eligible entity shall use funds awarded under this section
for--
``(A) the provision, by qualified primary care
professionals, of on site primary care services;
``(B) reasonable costs associated with medically necessary
referrals to qualified specialty care professionals, other
coordinators of care or, if permitted by the terms of the
grant or cooperative agreement, by qualified specialty care
professionals on a reasonable cost basis on site at the
eligible entity;
``(C) information technology required to accommodate the
clinical needs of primary and specialty care professionals;
or
``(D) facility modifications needed to bring primary and
specialty care professionals on site at the eligible entity.
``(2) Limitation.--Not to exceed 15 percent of grant or
cooperative agreement funds may be used for activities
described in subparagraphs (C) and (D) of paragraph (1).
``(e) Evaluation.--Not later than 90 days after a grant or
cooperative agreement awarded under this section expires, an
eligible entity shall submit to the Secretary the results of
an evaluation to be conducted by the entity concerning the
effectiveness of the activities carried out under the grant
or agreement.
``(f) Authorization of Appropriations.--There are
authorized to be appropriated to carry out this section,
$50,000,000 for fiscal year 2010 and such sums as may be
necessary for each of fiscal years 2011 through 2014.''.
SEC. 5605. KEY NATIONAL INDICATORS.
(a) Definitions.--In this section:
(1) Academy.--The term ``Academy'' means the National
Academy of Sciences.
(2) Commission.--The term ``Commission'' means the
Commission on Key National Indicators established under
subsection (b).
(3) Institute.--The term ``Institute'' means a Key National
Indicators Institute as designated under subsection (c)(3).
(b) Commission on Key National Indicators.--
(1) Establishment.--There is established a ``Commission on
Key National Indicators''.
(2) Membership.--
(A) Number and appointment.--The Commission shall be
composed of 8 members, to be appointed equally by the
majority and minority leaders of the Senate and the Speaker
and minority leader of the House of Representatives.
(B) Prohibited appointments.--Members of the Commission
shall not include Members of Congress or other elected
Federal, State, or local government officials.
(C) Qualifications.--In making appointments under
subparagraph (A), the majority and minority leaders of the
Senate and the Speaker and minority leader of the House of
Representatives shall appoint individuals who have shown a
dedication to improving civic dialogue and decision-making
through the wide use of scientific evidence and factual
information.
(D) Period of appointment.--Each member of the Commission
shall be appointed for a 2-year term, except that 1 initial
appointment shall be for 3 years. Any vacancies shall not
affect the power and duties of the Commission but shall be
filled in the same manner as the original appointment and
shall last only for the remainder of that term.
(E) Date.--Members of the Commission shall be appointed by
not later than 30 days after the date of enactment of this
Act.
(F) Initial organizing period.---Not later than 60 days
after the date of enactment of this Act, the Commission shall
develop and implement a schedule for completion of the review
and reports required under subsection (d).
(G) Co-chairpersons.--The Commission shall select 2 Co-
Chairpersons from among its members.
(c) Duties of the Commission.--
(1) In general.--The Commission shall--
(A) conduct comprehensive oversight of a newly established
key national indicators system consistent with the purpose
described in this subsection;
(B) make recommendations on how to improve the key national
indicators system;
(C) coordinate with Federal Government users and
information providers to assure access to relevant and
quality data; and
(D) enter into contracts with the Academy.
(2) Reports.--
(A) Annual report to congress.--Not later than 1 year after
the selection of the 2 Co-Chairpersons of the Commission, and
each subsequent year thereafter, the Commission shall prepare
and submit to the appropriate Committees of Congress and the
President a report that contains a detailed statement of the
recommendations, findings, and conclusions of the Commission
on the activities of the Academy and a designated Institute
related to the establishment of a Key National Indicator
System.
(B) Annual report to the academy.--
(i) In general.--Not later than 6 months after the
selection of the 2 Co-Chairpersons of the Commission, and
each subsequent year thereafter, the Commission shall prepare
and submit to the Academy and a designated Institute a report
making recommendations concerning potential issue areas and
key indicators to be included in the Key National Indicators.
(ii) Limitation.--The Commission shall not have the
authority to direct the Academy or, if established, the
Institute, to adopt, modify, or delete any key indicators.
(3) Contract with the national academy of sciences.--
(A) In general.---As soon as practicable after the
selection of the 2 Co-Chairpersons of the Commission, the Co-
Chairpersons shall enter into an arrangement with the
National Academy of Sciences under which the Academy shall--
(i) review available public and private sector research on
the selection of a set of key national indicators;
(ii) determine how best to establish a key national
indicator system for the United States, by either creating
its own institutional capability or designating an
independent private nonprofit organization as an Institute to
implement a key national indicator system;
(iii) if the Academy designates an independent Institute
under clause (ii), provide scientific and technical advice to
the Institute and create an appropriate governance mechanism
that balances Academy involvement and the independence of the
Institute; and
(iv) provide an annual report to the Commission addressing
scientific and technical issues related to the key national
indicator system and, if established, the Institute, and
governance of the Institute's budget and operations.
(B) Participation.--In executing the arrangement under
subparagraph (A), the National Academy of Sciences shall
convene a multi-sector, multi-disciplinary process to define
major scientific and technical issues associated with
developing, maintaining, and evolving a Key National
Indicator System and, if an Institute is established, to
provide it with scientific and technical advice.
(C) Establishment of a key national indicator system.--
(i) In general.--In executing the arrangement under
subparagraph (A), the National Academy of Sciences shall
enable the establishment of a key national indicator system
by--
(I) creating its own institutional capability; or
(II) partnering with an independent private nonprofit
organization as an Institute to implement a key national
indicator system.
(ii) Institute.--If the Academy designates an Institute
under clause (i)(II), such Institute shall be a non-profit
entity (as defined for purposes of section 501(c)(3) of the
Internal Revenue Code of 1986) with an educational mission, a
governance structure that emphasizes independence, and
characteristics that make such entity appropriate for
establishing a key national indicator system.
(iii) Responsibilities.--Either the Academy or the
Institute designated under clause (i)(II) shall be
responsible for the following:
(I) Identifying and selecting issue areas to be represented
by the key national indicators.
(II) Identifying and selecting the measures used for key
national indicators within the issue areas under subclause
(I).
(III) Identifying and selecting data to populate the key
national indicators described under subclause (II).
(IV) Designing, publishing, and maintaining a public
website that contains a freely accessible database allowing
public access to the key national indicators.
(V) Developing a quality assurance framework to ensure
rigorous and independent processes and the selection of
quality data.
(VI) Developing a budget for the construction and
management of a sustainable, adaptable, and evolving key
national indicator system that reflects all Commission
funding of Academy and, if an Institute is established,
Institute activities.
(VII) Reporting annually to the Commission regarding its
selection of issue areas, key indicators, data, and progress
toward establishing a web-accessible database.
(VIII) Responding directly to the Commission in response to
any Commission recommendations and to the Academy regarding
any inquiries by the Academy.
(iv) Governance.--Upon the establishment of a key national
indicator system, the Academy shall create an appropriate
governance mechanism that incorporates advisory and control
functions. If an Institute is designated under clause
(i)(II), the governance mechanism shall balance appropriate
Academy involvement and the independence of the Institute.
(v) Modification and changes.--The Academy shall retain the
sole discretion, at any time, to alter its approach to the
establishment of a key national indicator system or, if an
Institute is designated under clause (i)(II), to alter any
aspect of its relationship with the Institute or to designate
a different non-profit entity to serve as the Institute.
(vi) Construction.--Nothing in this section shall be
construed to limit the ability of the
[[Page H2066]]
Academy or the Institute designated under clause (i)(II) to
receive private funding for activities related to the
establishment of a key national indicator system.
(D) Annual report.--As part of the arrangement under
subparagraph (A), the National Academy of Sciences shall, not
later than 270 days after the date of enactment of this Act,
and annually thereafter, submit to the Co-Chairpersons of the
Commission a report that contains the findings and
recommendations of the Academy.
(d) Government Accountability Office Study and Report.--
(1) GAO study.--The Comptroller General of the United
States shall conduct a study of previous work conducted by
all public agencies, private organizations, or foreign
countries with respect to best practices for a key national
indicator system. The study shall be submitted to the
appropriate authorizing committees of Congress.
(2) GAO financial audit.--If an Institute is established
under this section, the Comptroller General shall conduct an
annual audit of the financial statements of the Institute, in
accordance with generally accepted government auditing
standards and submit a report on such audit to the Commission
and the appropriate authorizing committees of Congress.
(3) GAO programmatic review.--The Comptroller General of
the United States shall conduct programmatic assessments of
the Institute established under this section as determined
necessary by the Comptroller General and report the findings
to the Commission and to the appropriate authorizing
committees of Congress.
(e) Authorization of Appropriations.--
(1) In general.---There are authorized to be appropriated
to carry out the purposes of this section, $10,000,000 for
fiscal year 2010, and $7,500,000 for each of fiscal year 2011
through 2018.
(2) Availability.---Amounts appropriated under paragraph
(1) shall remain available until expended.
Subtitle H--General Provisions
SEC. 5701. REPORTS.
(a) Reports by Secretary of Health and Human Services.--On
an annual basis, the Secretary of Health and Human Services
shall submit to the appropriate Committees of Congress a
report on the activities carried out under the amendments
made by this title, and the effectiveness of such activities.
(b) Reports by Recipients of Funds.--The Secretary of
Health and Human Services may require, as a condition of
receiving funds under the amendments made by this title, that
the entity receiving such award submit to such Secretary such
reports as the such Secretary may require on activities
carried out with such award, and the effectiveness of such
activities.
TITLE VI--TRANSPARENCY AND PROGRAM INTEGRITY
Subtitle A--Physician Ownership and Other Transparency
SEC. 6001. LIMITATION ON MEDICARE EXCEPTION TO THE
PROHIBITION ON CERTAIN PHYSICIAN REFERRALS FOR
HOSPITALS.
(a) In General.--Section 1877 of the Social Security Act
(42 U.S.C. 1395nn) is amended--
(1) in subsection (d)(2)--
(A) in subparagraph (A), by striking ``and'' at the end;
(B) in subparagraph (B), by striking the period at the end
and inserting ``; and''; and
(C) by adding at the end the following new subparagraph:
``(C) in the case where the entity is a hospital, the
hospital meets the requirements of paragraph (3)(D).'';
(2) in subsection (d)(3)--
(A) in subparagraph (B), by striking ``and'' at the end;
(B) in subparagraph (C), by striking the period at the end
and inserting ``; and''; and
(C) by adding at the end the following new subparagraph:
``(D) the hospital meets the requirements described in
subsection (i)(1) not later than 18 months after the date of
the enactment of this subparagraph.''; and
(3) by adding at the end the following new subsection:
``(i) Requirements for Hospitals To Qualify for Rural
Provider and Hospital Exception to Ownership or Investment
Prohibition.--
``(1) Requirements described.--For purposes of subsection
(d)(3)(D), the requirements described in this paragraph for a
hospital are as follows:
``(A) Provider agreement.--The hospital had--
``(i) physician ownership or investment on February 1,
2010; and
``(ii) a provider agreement under section 1866 in effect on
such date.
``(B) Limitation on expansion of facility capacity.--Except
as provided in paragraph (3), the number of operating rooms,
procedure rooms, and beds for which the hospital is licensed
at any time on or after the date of the enactment of this
subsection is no greater than the number of operating rooms,
procedure rooms, and beds for which the hospital is licensed
as of such date.
``(C) Preventing conflicts of interest.--
``(i) The hospital submits to the Secretary an annual
report containing a detailed description of--
``(I) the identity of each physician owner or investor and
any other owners or investors of the hospital; and
``(II) the nature and extent of all ownership and
investment interests in the hospital.
``(ii) The hospital has procedures in place to require that
any referring physician owner or investor discloses to the
patient being referred, by a time that permits the patient to
make a meaningful decision regarding the receipt of care, as
determined by the Secretary--
``(I) the ownership or investment interest, as applicable,
of such referring physician in the hospital; and
``(II) if applicable, any such ownership or investment
interest of the treating physician.
``(iii) The hospital does not condition any physician
ownership or investment interests either directly or
indirectly on the physician owner or investor making or
influencing referrals to the hospital or otherwise generating
business for the hospital.
``(iv) The hospital discloses the fact that the hospital is
partially owned or invested in by physicians--
``(I) on any public website for the hospital; and
``(II) in any public advertising for the hospital.
``(D) Ensuring bona fide investment.--
``(i) The percentage of the total value of the ownership or
investment interests held in the hospital, or in an entity
whose assets include the hospital, by physician owners or
investors in the aggregate does not exceed such percentage as
of the date of enactment of this subsection.
``(ii) Any ownership or investment interests that the
hospital offers to a physician owner or investor are not
offered on more favorable terms than the terms offered to a
person who is not a physician owner or investor.
``(iii) The hospital (or any owner or investor in the
hospital) does not directly or indirectly provide loans or
financing for any investment in the hospital by a physician
owner or investor.
``(iv) The hospital (or any owner or investor in the
hospital) does not directly or indirectly guarantee a loan,
make a payment toward a loan, or otherwise subsidize a loan,
for any individual physician owner or investor or group of
physician owners or investors that is related to acquiring
any ownership or investment interest in the hospital.
``(v) Ownership or investment returns are distributed to
each owner or investor in the hospital in an amount that is
directly proportional to the ownership or investment interest
of such owner or investor in the hospital.
``(vi) Physician owners and investors do not receive,
directly or indirectly, any guaranteed receipt of or right to
purchase other business interests related to the hospital,
including the purchase or lease of any property under the
control of other owners or investors in the hospital or
located near the premises of the hospital.
``(vii) The hospital does not offer a physician owner or
investor the opportunity to purchase or lease any property
under the control of the hospital or any other owner or
investor in the hospital on more favorable terms than the
terms offered to an individual who is not a physician owner
or investor.
``(E) Patient safety.--
``(i) Insofar as the hospital admits a patient and does not
have any physician available on the premises to provide
services during all hours in which the hospital is providing
services to such patient, before admitting the patient--
``(I) the hospital discloses such fact to a patient; and
``(II) following such disclosure, the hospital receives
from the patient a signed acknowledgment that the patient
understands such fact.
``(ii) The hospital has the capacity to--
``(I) provide assessment and initial treatment for
patients; and
``(II) refer and transfer patients to hospitals with the
capability to treat the needs of the patient involved.
``(F) Limitation on application to certain converted
facilities.--The hospital was not converted from an
ambulatory surgical center to a hospital on or after the date
of enactment of this subsection.
``(2) Publication of information reported.--The Secretary
shall publish, and update on an annual basis, the information
submitted by hospitals under paragraph (1)(C)(i) on the
public Internet website of the Centers for Medicare &
Medicaid Services.
``(3) Exception to prohibition on expansion of facility
capacity.--
``(A) Process.--
``(i) Establishment.--The Secretary shall establish and
implement a process under which an applicable hospital (as
defined in subparagraph (E)) may apply for an exception from
the requirement under paragraph (1)(B).
``(ii) Opportunity for community input.--The process under
clause (i) shall provide individuals and entities in the
community in which the applicable hospital applying for an
exception is located with the opportunity to provide input
with respect to the application.
``(iii) Timing for implementation.--The Secretary shall
implement the process under clause (i) on August 1, 2011.
``(iv) Regulations.--Not later than July 1, 2011, the
Secretary shall promulgate regulations to carry out the
process under clause (i).
``(B) Frequency.--The process described in subparagraph (A)
shall permit an applicable hospital to apply for an exception
up to once every 2 years.
``(C) Permitted increase.--
``(i) In general.--Subject to clause (ii) and subparagraph
(D), an applicable hospital granted an exception under the
process described in subparagraph (A) may increase the number
of operating rooms, procedure rooms, and beds for which the
applicable hospital is licensed above the baseline number of
operating rooms, procedure rooms, and beds of the applicable
hospital (or, if the applicable hospital has been granted a
previous exception under this paragraph, above the number of
operating rooms, procedure rooms, and beds for which the
hospital is licensed after the application of the most recent
increase under such an exception).
``(ii) 100 percent increase limitation.--The Secretary
shall not permit an increase in the
[[Page H2067]]
number of operating rooms, procedure rooms, and beds for
which an applicable hospital is licensed under clause (i) to
the extent such increase would result in the number of
operating rooms, procedure rooms, and beds for which the
applicable hospital is licensed exceeding 200 percent of the
baseline number of operating rooms, procedure rooms, and beds
of the applicable hospital.
``(iii) Baseline number of operating rooms, procedure
rooms, and beds.--In this paragraph, the term `baseline
number of operating rooms, procedure rooms, and beds' means
the number of operating rooms, procedure rooms, and beds for
which the applicable hospital is licensed as of the date of
enactment of this subsection.
``(D) Increase limited to facilities on the main campus of
the hospital.--Any increase in the number of operating rooms,
procedure rooms, and beds for which an applicable hospital is
licensed pursuant to this paragraph may only occur in
facilities on the main campus of the applicable hospital.
``(E) Applicable hospital.--In this paragraph, the term
`applicable hospital' means a hospital--
``(i) that is located in a county in which the percentage
increase in the population during the most recent 5-year
period (as of the date of the application under subparagraph
(A)) is at least 150 percent of the percentage increase in
the population growth of the State in which the hospital is
located during that period, as estimated by Bureau of the
Census;
``(ii) whose annual percent of total inpatient admissions
that represent inpatient admissions under the program under
title XIX is equal to or greater than the average percent
with respect to such admissions for all hospitals located in
the county in which the hospital is located;
``(iii) that does not discriminate against beneficiaries of
Federal health care programs and does not permit physicians
practicing at the hospital to discriminate against such
beneficiaries;
``(iv) that is located in a State in which the average bed
capacity in the State is less than the national average bed
capacity; and
``(v) that has an average bed occupancy rate that is
greater than the average bed occupancy rate in the State in
which the hospital is located.
``(F) Procedure rooms.--In this subsection, the term
`procedure rooms' includes rooms in which catheterizations,
angiographies, angiograms, and endoscopies are performed,
except such term shall not include emergency rooms or
departments (exclusive of rooms in which catheterizations,
angiographies, angiograms, and endoscopies are performed).
``(G) Publication of final decisions.--Not later than 60
days after receiving a complete application under this
paragraph, the Secretary shall publish in the Federal
Register the final decision with respect to such application.
``(H) Limitation on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of the process under this paragraph
(including the establishment of such process).
``(4) Collection of ownership and investment information.--
For purposes of subparagraphs (A)(i) and (D)(i) of paragraph
(1), the Secretary shall collect physician ownership and
investment information for each hospital.
``(5) Physician owner or investor defined.--For purposes of
this subsection, the term `physician owner or investor' means
a physician (or an immediate family member of such physician)
with a direct or an indirect ownership or investment interest
in the hospital.
``(6) Clarification.--Nothing in this subsection shall be
construed as preventing the Secretary from revoking a
hospital's provider agreement if not in compliance with
regulations implementing section 1866.''.
(b) Enforcement.--
(1) Ensuring compliance.--The Secretary of Health and Human
Services shall establish policies and procedures to ensure
compliance with the requirements described in subsection
(i)(1) of section 1877 of the Social Security Act, as added
by subsection (a)(3), beginning on the date such requirements
first apply. Such policies and procedures may include
unannounced site reviews of hospitals.
(2) Audits.--Beginning not later than November 1, 2011, the
Secretary of Health and Human Services shall conduct audits
to determine if hospitals violate the requirements referred
to in paragraph (1).
SEC. 6002. TRANSPARENCY REPORTS AND REPORTING OF PHYSICIAN
OWNERSHIP OR INVESTMENT INTERESTS.
Part A of title XI of the Social Security Act (42 U.S.C.
1301 et seq.) is amended by inserting after section 1128F the
following new section:
``SEC. 1128G. TRANSPARENCY REPORTS AND REPORTING OF PHYSICIAN
OWNERSHIP OR INVESTMENT INTERESTS.
``(a) Transparency Reports.--
``(1) Payments or other transfers of value.--
``(A) In general.--On March 31, 2013, and on the 90th day
of each calendar year beginning thereafter, any applicable
manufacturer that provides a payment or other transfer of
value to a covered recipient (or to an entity or individual
at the request of or designated on behalf of a covered
recipient), shall submit to the Secretary, in such electronic
form as the Secretary shall require, the following
information with respect to the preceding calendar year:
``(i) The name of the covered recipient.
``(ii) The business address of the covered recipient and,
in the case of a covered recipient who is a physician, the
specialty and National Provider Identifier of the covered
recipient.
``(iii) The amount of the payment or other transfer of
value.
``(iv) The dates on which the payment or other transfer of
value was provided to the covered recipient.
``(v) A description of the form of the payment or other
transfer of value, indicated (as appropriate for all that
apply) as--
``(I) cash or a cash equivalent;
``(II) in-kind items or services;
``(III) stock, a stock option, or any other ownership
interest, dividend, profit, or other return on investment; or
``(IV) any other form of payment or other transfer of value
(as defined by the Secretary).
``(vi) A description of the nature of the payment or other
transfer of value, indicated (as appropriate for all that
apply) as--
``(I) consulting fees;
``(II) compensation for services other than consulting;
``(III) honoraria;
``(IV) gift;
``(V) entertainment;
``(VI) food;
``(VII) travel (including the specified destinations);
``(VIII) education;
``(IX) research;
``(X) charitable contribution;
``(XI) royalty or license;
``(XII) current or prospective ownership or investment
interest;
``(XIII) direct compensation for serving as faculty or as a
speaker for a medical education program;
``(XIV) grant; or
``(XV) any other nature of the payment or other transfer of
value (as defined by the Secretary).
``(vii) If the payment or other transfer of value is
related to marketing, education, or research specific to a
covered drug, device, biological, or medical supply, the name
of that covered drug, device, biological, or medical supply.
``(viii) Any other categories of information regarding the
payment or other transfer of value the Secretary determines
appropriate.
``(B) Special rule for certain payments or other transfers
of value.--In the case where an applicable manufacturer
provides a payment or other transfer of value to an entity or
individual at the request of or designated on behalf of a
covered recipient, the applicable manufacturer shall disclose
that payment or other transfer of value under the name of the
covered recipient.
``(2) Physician ownership.--In addition to the requirement
under paragraph (1)(A), on March 31, 2013, and on the 90th
day of each calendar year beginning thereafter, any
applicable manufacturer or applicable group purchasing
organization shall submit to the Secretary, in such
electronic form as the Secretary shall require, the following
information regarding any ownership or investment interest
(other than an ownership or investment interest in a publicly
traded security and mutual fund, as described in section
1877(c)) held by a physician (or an immediate family member
of such physician (as defined for purposes of section
1877(a))) in the applicable manufacturer or applicable group
purchasing organization during the preceding year:
``(A) The dollar amount invested by each physician holding
such an ownership or investment interest.
``(B) The value and terms of each such ownership or
investment interest.
``(C) Any payment or other transfer of value provided to a
physician holding such an ownership or investment interest
(or to an entity or individual at the request of or
designated on behalf of a physician holding such an ownership
or investment interest), including the information described
in clauses (i) through (viii) of paragraph (1)(A), except
that in applying such clauses, `physician' shall be
substituted for `covered recipient' each place it appears.
``(D) Any other information regarding the ownership or
investment interest the Secretary determines appropriate.
``(b) Penalties for Noncompliance.--
``(1) Failure to report.--
``(A) In general.--Subject to subparagraph (B) except as
provided in paragraph (2), any applicable manufacturer or
applicable group purchasing organization that fails to submit
information required under subsection (a) in a timely manner
in accordance with rules or regulations promulgated to carry
out such subsection, shall be subject to a civil money
penalty of not less than $1,000, but not more than $10,000,
for each payment or other transfer of value or ownership or
investment interest not reported as required under such
subsection. Such penalty shall be imposed and collected in
the same manner as civil money penalties under subsection (a)
of section 1128A are imposed and collected under that
section.
``(B) Limitation.--The total amount of civil money
penalties imposed under subparagraph (A) with respect to each
annual submission of information under subsection (a) by an
applicable manufacturer or applicable group purchasing
organization shall not exceed $150,000.
``(2) Knowing failure to report.--
``(A) In general.--Subject to subparagraph (B), any
applicable manufacturer or applicable group purchasing
organization that knowingly fails to submit information
required under subsection (a) in a timely manner in
accordance with rules or regulations promulgated to carry out
such subsection, shall be subject to a civil money penalty of
not less than $10,000, but not more than $100,000, for each
payment or other transfer of value or ownership or investment
interest not reported as required under such subsection. Such
penalty shall be imposed and collected in the same manner as
civil money penalties under subsection (a) of section 1128A
are imposed and collected under that section.
``(B) Limitation.--The total amount of civil money
penalties imposed under subparagraph (A) with respect to each
annual submission of information under subsection (a) by an
applicable manufacturer or applicable group purchasing
organization shall not exceed $1,000,000.
[[Page H2068]]
``(3) Use of funds.--Funds collected by the Secretary as a
result of the imposition of a civil money penalty under this
subsection shall be used to carry out this section.
``(c) Procedures for Submission of Information and Public
Availability.--
``(1) In general.--
``(A) Establishment.--Not later than October 1, 2011, the
Secretary shall establish procedures--
``(i) for applicable manufacturers and applicable group
purchasing organizations to submit information to the
Secretary under subsection (a); and
``(ii) for the Secretary to make such information submitted
available to the public.
``(B) Definition of terms.--The procedures established
under subparagraph (A) shall provide for the definition of
terms (other than those terms defined in subsection (e)), as
appropriate, for purposes of this section.
``(C) Public availability.--Except as provided in
subparagraph (E), the procedures established under
subparagraph (A)(ii) shall ensure that, not later than
September 30, 2013, and on June 30 of each calendar year
beginning thereafter, the information submitted under
subsection (a) with respect to the preceding calendar year is
made available through an Internet website that--
``(i) is searchable and is in a format that is clear and
understandable;
``(ii) contains information that is presented by the name
of the applicable manufacturer or applicable group purchasing
organization, the name of the covered recipient, the business
address of the covered recipient, the specialty of the
covered recipient, the value of the payment or other transfer
of value, the date on which the payment or other transfer of
value was provided to the covered recipient, the form of the
payment or other transfer of value, indicated (as
appropriate) under subsection (a)(1)(A)(v), the nature of the
payment or other transfer of value, indicated (as
appropriate) under subsection (a)(1)(A)(vi), and the name of
the covered drug, device, biological, or medical supply, as
applicable;
``(iii) contains information that is able to be easily
aggregated and downloaded;
``(iv) contains a description of any enforcement actions
taken to carry out this section, including any penalties
imposed under subsection (b), during the preceding year;
``(v) contains background information on industry-physician
relationships;
``(vi) in the case of information submitted with respect to
a payment or other transfer of value described in
subparagraph (E)(i), lists such information separately from
the other information submitted under subsection (a) and
designates such separately listed information as funding for
clinical research;
``(vii) contains any other information the Secretary
determines would be helpful to the average consumer;
``(viii) does not contain the National Provider Identifier
of the covered recipient, and
``(ix) subject to subparagraph (D), provides the applicable
manufacturer, applicable group purchasing organization, or
covered recipient an opportunity to review and submit
corrections to the information submitted with respect to the
applicable manufacturer, applicable group purchasing
organization, or covered recipient, respectively, for a
period of not less than 45 days prior to such information
being made available to the public.
``(D) Clarification of time period for review and
corrections.--In no case may the 45-day period for review and
submission of corrections to information under subparagraph
(C)(ix) prevent such information from being made available to
the public in accordance with the dates described in the
matter preceding clause (i) in subparagraph (C).
``(E) Delayed publication for payments made pursuant to
product research or development agreements and clinical
investigations.--
``(i) In general.--In the case of information submitted
under subsection (a) with respect to a payment or other
transfer of value made to a covered recipient by an
applicable manufacturer pursuant to a product research or
development agreement for services furnished in connection
with research on a potential new medical technology or a new
application of an existing medical technology or the
development of a new drug, device, biological, or medical
supply, or by an applicable manufacturer in connection with a
clinical investigation regarding a new drug, device,
biological, or medical supply, the procedures established
under subparagraph (A)(ii) shall provide that such
information is made available to the public on the first date
described in the matter preceding clause (i) in subparagraph
(C) after the earlier of the following:
``(I) The date of the approval or clearance of the covered
drug, device, biological, or medical supply by the Food and
Drug Administration.
``(II) Four calendar years after the date such payment or
other transfer of value was made.
``(ii) Confidentiality of information prior to
publication.--Information described in clause (i) shall be
considered confidential and shall not be subject to
disclosure under section 552 of title 5, United States Code,
or any other similar Federal, State, or local law, until on
or after the date on which the information is made available
to the public under such clause.
``(2) Consultation.--In establishing the procedures under
paragraph (1), the Secretary shall consult with the Inspector
General of the Department of Health and Human Services,
affected industry, consumers, consumer advocates, and other
interested parties in order to ensure that the information
made available to the public under such paragraph is
presented in the appropriate overall context.
``(d) Annual Reports and Relation to State Laws.--
``(1) Annual report to congress.--Not later than April 1 of
each year beginning with 2013, the Secretary shall submit to
Congress a report that includes the following:
``(A) The information submitted under subsection (a) during
the preceding year, aggregated for each applicable
manufacturer and applicable group purchasing organization
that submitted such information during such year (except, in
the case of information submitted with respect to a payment
or other transfer of value described in subsection
(c)(1)(E)(i), such information shall be included in the first
report submitted to Congress after the date on which such
information is made available to the public under such
subsection).
``(B) A description of any enforcement actions taken to
carry out this section, including any penalties imposed under
subsection (b), during the preceding year.
``(2) Annual reports to states.--Not later than September
30, 2013 and on June 30 of each calendar year thereafter, the
Secretary shall submit to States a report that includes a
summary of the information submitted under subsection (a)
during the preceding year with respect to covered recipients
in the State (except, in the case of information submitted
with respect to a payment or other transfer of value
described in subsection (c)(1)(E)(i), such information shall
be included in the first report submitted to States after the
date on which such information is made available to the
public under such subsection).
``(3) Relation to state laws.--
``(A) In general.--In the case of a payment or other
transfer of value provided by an applicable manufacturer that
is received by a covered recipient (as defined in subsection
(e)) on or after January 1, 2012, subject to subparagraph
(B), the provisions of this section shall preempt any statute
or regulation of a State or of a political subdivision of a
State that requires an applicable manufacturer (as so
defined) to disclose or report, in any format, the type of
information (as described in subsection (a)) regarding such
payment or other transfer of value.
``(B) No preemption of additional requirements.--
Subparagraph (A) shall not preempt any statute or regulation
of a State or of a political subdivision of a State that
requires the disclosure or reporting of information--
``(i) not of the type required to be disclosed or reported
under this section;
``(ii) described in subsection (e)(10)(B), except in the
case of information described in clause (i) of such
subsection;
``(iii) by any person or entity other than an applicable
manufacturer (as so defined) or a covered recipient (as
defined in subsection (e)); or
``(iv) to a Federal, State, or local governmental agency
for public health surveillance, investigation, or other
public health purposes or health oversight purposes.
``(C) Nothing in subparagraph (A) shall be construed to
limit the discovery or admissibility of information described
in such subparagraph in a criminal, civil, or administrative
proceeding.
``(4) Consultation.--The Secretary shall consult with the
Inspector General of the Department of Health and Human
Services on the implementation of this section.
``(e) Definitions.--In this section:
``(1) Applicable group purchasing organization.--The term
`applicable group purchasing organization' means a group
purchasing organization (as defined by the Secretary) that
purchases, arranges for, or negotiates the purchase of a
covered drug, device, biological, or medical supply which is
operating in the United States, or in a territory,
possession, or commonwealth of the United States.
``(2) Applicable manufacturer.--The term `applicable
manufacturer' means a manufacturer of a covered drug, device,
biological, or medical supply which is operating in the
United States, or in a territory, possession, or commonwealth
of the United States.
``(3) Clinical investigation.--The term `clinical
investigation' means any experiment involving 1 or more human
subjects, or materials derived from human subjects, in which
a drug or device is administered, dispensed, or used.
``(4) Covered device.--The term `covered device' means any
device for which payment is available under title XVIII or a
State plan under title XIX or XXI (or a waiver of such a
plan).
``(5) Covered drug, device, biological, or medical
supply.--The term `covered drug, device, biological, or
medical supply' means any drug, biological product, device,
or medical supply for which payment is available under title
XVIII or a State plan under title XIX or XXI (or a waiver of
such a plan).
``(6) Covered recipient.--
``(A) In general.--Except as provided in subparagraph (B),
the term `covered recipient' means the following:
``(i) A physician.
``(ii) A teaching hospital.
``(B) Exclusion.--Such term does not include a physician
who is an employee of the applicable manufacturer that is
required to submit information under subsection (a).
``(7) Employee.--The term `employee' has the meaning given
such term in section 1877(h)(2).
``(8) Knowingly.--The term `knowingly' has the meaning
given such term in section 3729(b) of title 31, United States
Code.
``(9) Manufacturer of a covered drug, device, biological,
or medical supply.--The term `manufacturer of a covered drug,
device, biological, or medical supply' means any entity which
is engaged in the production, preparation, propagation,
compounding, or conversion of a covered drug, device,
biological, or medical supply (or any entity under common
ownership with such entity which provides assistance or
support to such entity with respect to the production,
preparation, propagation,
[[Page H2069]]
compounding, conversion, marketing, promotion, sale, or
distribution of a covered drug, device, biological, or
medical supply).
``(10) Payment or other transfer of value.--
``(A) In general.--The term `payment or other transfer of
value' means a transfer of anything of value. Such term does
not include a transfer of anything of value that is made
indirectly to a covered recipient through a third party in
connection with an activity or service in the case where the
applicable manufacturer is unaware of the identity of the
covered recipient.
``(B) Exclusions.--An applicable manufacturer shall not be
required to submit information under subsection (a) with
respect to the following:
``(i) A transfer of anything the value of which is less
than $10, unless the aggregate amount transferred to,
requested by, or designated on behalf of the covered
recipient by the applicable manufacturer during the calendar
year exceeds $100. For calendar years after 2012, the dollar
amounts specified in the preceding sentence shall be
increased by the same percentage as the percentage increase
in the consumer price index for all urban consumers (all
items; U.S. city average) for the 12-month period ending with
June of the previous year.
``(ii) Product samples that are not intended to be sold and
are intended for patient use.
``(iii) Educational materials that directly benefit
patients or are intended for patient use.
``(iv) The loan of a covered device for a short-term trial
period, not to exceed 90 days, to permit evaluation of the
covered device by the covered recipient.
``(v) Items or services provided under a contractual
warranty, including the replacement of a covered device,
where the terms of the warranty are set forth in the purchase
or lease agreement for the covered device.
``(vi) A transfer of anything of value to a covered
recipient when the covered recipient is a patient and not
acting in the professional capacity of a covered recipient.
``(vii) Discounts (including rebates).
``(viii) In-kind items used for the provision of charity
care.
``(ix) A dividend or other profit distribution from, or
ownership or investment interest in, a publicly traded
security and mutual fund (as described in section 1877(c)).
``(x) In the case of an applicable manufacturer who offers
a self-insured plan, payments for the provision of health
care to employees under the plan.
``(xi) In the case of a covered recipient who is a licensed
non-medical professional, a transfer of anything of value to
the covered recipient if the transfer is payment solely for
the non-medical professional services of such licensed non-
medical professional.
``(xii) In the case of a covered recipient who is a
physician, a transfer of anything of value to the covered
recipient if the transfer is payment solely for the services
of the covered recipient with respect to a civil or criminal
action or an administrative proceeding.
``(11) Physician.--The term `physician' has the meaning
given that term in section 1861(r).''.
SEC. 6003. DISCLOSURE REQUIREMENTS FOR IN-OFFICE ANCILLARY
SERVICES EXCEPTION TO THE PROHIBITION ON
PHYSICIAN SELF-REFERRAL FOR CERTAIN IMAGING
SERVICES.
(a) In General.--Section 1877(b)(2) of the Social Security
Act (42 U.S.C. 1395nn(b)(2)) is amended by adding at the end
the following new sentence: ``Such requirements shall, with
respect to magnetic resonance imaging, computed tomography,
positron emission tomography, and any other designated health
services specified under subsection (h)(6)(D) that the
Secretary determines appropriate, include a requirement that
the referring physician inform the individual in writing at
the time of the referral that the individual may obtain the
services for which the individual is being referred from a
person other than a person described in subparagraph (A)(i)
and provide such individual with a written list of suppliers
(as defined in section 1861(d)) who furnish such services in
the area in which such individual resides.''.
(b) Effective Date.--The amendment made by this section
shall apply to services furnished on or after January 1,
2010.
SEC. 6004. PRESCRIPTION DRUG SAMPLE TRANSPARENCY.
Part A of title XI of the Social Security Act (42 U.S.C.
1301 et seq.), as amended by section 6002, is amended by
inserting after section 1128G the following new section:
``SEC. 1128H. REPORTING OF INFORMATION RELATING TO DRUG
SAMPLES.
``(a) In General.--Not later than April 1 of each year
(beginning with 2012), each manufacturer and authorized
distributor of record of an applicable drug shall submit to
the Secretary (in a form and manner specified by the
Secretary) the following information with respect to the
preceding year:
``(1) In the case of a manufacturer or authorized
distributor of record which makes distributions by mail or
common carrier under subsection (d)(2) of section 503 of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 353), the
identity and quantity of drug samples requested and the
identity and quantity of drug samples distributed under such
subsection during that year, aggregated by--
``(A) the name, address, professional designation, and
signature of the practitioner making the request under
subparagraph (A)(i) of such subsection, or of any individual
who makes or signs for the request on behalf of the
practitioner; and
``(B) any other category of information determined
appropriate by the Secretary.
``(2) In the case of a manufacturer or authorized
distributor of record which makes distributions by means
other than mail or common carrier under subsection (d)(3) of
such section 503, the identity and quantity of drug samples
requested and the identity and quantity of drug samples
distributed under such subsection during that year,
aggregated by--
``(A) the name, address, professional designation, and
signature of the practitioner making the request under
subparagraph (A)(i) of such subsection, or of any individual
who makes or signs for the request on behalf of the
practitioner; and
``(B) any other category of information determined
appropriate by the Secretary.
``(b) Definitions.--In this section:
``(1) Applicable drug.--The term `applicable drug' means a
drug--
``(A) which is subject to subsection (b) of such section
503; and
``(B) for which payment is available under title XVIII or a
State plan under title XIX or XXI (or a waiver of such a
plan).
``(2) Authorized distributor of record.--The term
`authorized distributor of record' has the meaning given that
term in subsection (e)(3)(A) of such section.
``(3) Manufacturer.--The term `manufacturer' has the
meaning given that term for purposes of subsection (d) of
such section.''.
SEC. 6005. PHARMACY BENEFIT MANAGERS TRANSPARENCY
REQUIREMENTS.
Part A of title XI of the Social Security Act (42 U.S.C.
1301 et seq.) is amended by inserting after section 1150 the
following new section:
``SEC. 1150A. PHARMACY BENEFIT MANAGERS TRANSPARENCY
REQUIREMENTS.
``(a) Provision of Information.--A health benefits plan or
any entity that provides pharmacy benefits management
services on behalf of a health benefits plan (in this section
referred to as a `PBM') that manages prescription drug
coverage under a contract with--
``(1) a PDP sponsor of a prescription drug plan or an MA
organization offering an MA-PD plan under part D of title
XVIII; or
``(2) a qualified health benefits plan offered through an
exchange established by a State under section 1311 of the
Patient Protection and Affordable Care Act,
shall provide the information described in subsection (b) to
the Secretary and, in the case of a PBM, to the plan with
which the PBM is under contract with, at such times, and in
such form and manner, as the Secretary shall specify.
``(b) Information Described.--The information described in
this subsection is the following with respect to services
provided by a health benefits plan or PBM for a contract
year:
``(1) The percentage of all prescriptions that were
provided through retail pharmacies compared to mail order
pharmacies, and the percentage of prescriptions for which a
generic drug was available and dispensed (generic dispensing
rate), by pharmacy type (which includes an independent
pharmacy, chain pharmacy, supermarket pharmacy, or mass
merchandiser pharmacy that is licensed as a pharmacy by the
State and that dispenses medication to the general public),
that is paid by the health benefits plan or PBM under the
contract.
``(2) The aggregate amount, and the type of rebates,
discounts, or price concessions (excluding bona fide service
fees, which include but are not limited to distribution
service fees, inventory management fees, product stocking
allowances, and fees associated with administrative services
agreements and patient care programs (such as medication
compliance programs and patient education programs)) that the
PBM negotiates that are attributable to patient utilization
under the plan, and the aggregate amount of the rebates,
discounts, or price concessions that are passed through to
the plan sponsor, and the total number of prescriptions that
were dispensed.
``(3) The aggregate amount of the difference between the
amount the health benefits plan pays the PBM and the amount
that the PBM pays retail pharmacies, and mail order
pharmacies, and the total number of prescriptions that were
dispensed.
``(c) Confidentiality.--Information disclosed by a health
benefits plan or PBM under this section is confidential and
shall not be disclosed by the Secretary or by a plan
receiving the information, except that the Secretary may
disclose the information in a form which does not disclose
the identity of a specific PBM, plan, or prices charged for
drugs, for the following purposes:
``(1) As the Secretary determines to be necessary to carry
out this section or part D of title XVIII.
``(2) To permit the Comptroller General to review the
information provided.
``(3) To permit the Director of the Congressional Budget
Office to review the information provided.
``(4) To States to carry out section 1311 of the Patient
Protection and Affordable Care Act.
``(d) Penalties.--The provisions of subsection (b)(3)(C) of
section 1927 shall apply to a health benefits plan or PBM
that fails to provide information required under subsection
(a) on a timely basis or that knowingly provides false
information in the same manner as such provisions apply to a
manufacturer with an agreement under that section.''.
Subtitle B--Nursing Home Transparency and Improvement
PART I--IMPROVING TRANSPARENCY OF INFORMATION
SEC. 6101. REQUIRED DISCLOSURE OF OWNERSHIP AND ADDITIONAL
DISCLOSABLE PARTIES INFORMATION.
(a) In General.--Section 1124 of the Social Security Act
(42 U.S.C. 1320a-3) is amended by adding at the end the
following new subsection:
``(c) Required Disclosure of Ownership and Additional
Disclosable Parties Information.--
[[Page H2070]]
``(1) Disclosure.--A facility shall have the information
described in paragraph (2) available--
``(A) during the period beginning on the date of the
enactment of this subsection and ending on the date such
information is made available to the public under section
6101(b) of the Patient Protection and Affordable Care Act for
submission to the Secretary, the Inspector General of the
Department of Health and Human Services, the State in which
the facility is located, and the State long-term care
ombudsman in the case where the Secretary, the Inspector
General, the State, or the State long-term care ombudsman
requests such information; and
``(B) beginning on the effective date of the final
regulations promulgated under paragraph (3)(A), for reporting
such information in accordance with such final regulations.
Nothing in subparagraph (A) shall be construed as authorizing
a facility to dispose of or delete information described in
such subparagraph after the effective date of the final
regulations promulgated under paragraph (3)(A).
``(2) Information described.--
``(A) In general.--The following information is described
in this paragraph:
``(i) The information described in subsections (a) and (b),
subject to subparagraph (C).
``(ii) The identity of and information on--
``(I) each member of the governing body of the facility,
including the name, title, and period of service of each such
member;
``(II) each person or entity who is an officer, director,
member, partner, trustee, or managing employee of the
facility, including the name, title, and period of service of
each such person or entity; and
``(III) each person or entity who is an additional
disclosable party of the facility.
``(iii) The organizational structure of each additional
disclosable party of the facility and a description of the
relationship of each such additional disclosable party to the
facility and to one another.
``(B) Special rule where information is already reported or
submitted.--To the extent that information reported by a
facility to the Internal Revenue Service on Form 990,
information submitted by a facility to the Securities and
Exchange Commission, or information otherwise submitted to
the Secretary or any other Federal agency contains the
information described in clauses (i), (ii), or (iii) of
subparagraph (A), the facility may provide such Form or such
information submitted to meet the requirements of paragraph
(1).
``(C) Special rule.--In applying subparagraph (A)(i)--
``(i) with respect to subsections (a) and (b), `ownership
or control interest' shall include direct or indirect
interests, including such interests in intermediate entities;
and
``(ii) subsection (a)(3)(A)(ii) shall include the owner of
a whole or part interest in any mortgage, deed of trust,
note, or other obligation secured, in whole or in part, by
the entity or any of the property or assets thereof, if the
interest is equal to or exceeds 5 percent of the total
property or assets of the entirety.
``(3) Reporting.--
``(A) In general.--Not later than the date that is 2 years
after the date of the enactment of this subsection, the
Secretary shall promulgate final regulations requiring,
effective on the date that is 90 days after the date on which
such final regulations are published in the Federal Register,
a facility to report the information described in paragraph
(2) to the Secretary in a standardized format, and such other
regulations as are necessary to carry out this subsection.
Such final regulations shall ensure that the facility
certifies, as a condition of participation and payment under
the program under title XVIII or XIX, that the information
reported by the facility in accordance with such final
regulations is, to the best of the facility's knowledge,
accurate and current.
``(B) Guidance.--The Secretary shall provide guidance and
technical assistance to States on how to adopt the
standardized format under subparagraph (A).
``(4) No effect on existing reporting requirements.--
Nothing in this subsection shall reduce, diminish, or alter
any reporting requirement for a facility that is in effect as
of the date of the enactment of this subsection.
``(5) Definitions.--In this subsection:
``(A) Additional disclosable party.--The term `additional
disclosable party' means, with respect to a facility, any
person or entity who--
``(i) exercises operational, financial, or managerial
control over the facility or a part thereof, or provides
policies or procedures for any of the operations of the
facility, or provides financial or cash management services
to the facility;
``(ii) leases or subleases real property to the facility,
or owns a whole or part interest equal to or exceeding 5
percent of the total value of such real property; or
``(iii) provides management or administrative services,
management or clinical consulting services, or accounting or
financial services to the facility.
``(B) Facility.--The term `facility' means a disclosing
entity which is--
``(i) a skilled nursing facility (as defined in section
1819(a)); or
``(ii) a nursing facility (as defined in section 1919(a)).
``(C) Managing employee.--The term `managing employee'
means, with respect to a facility, an individual (including a
general manager, business manager, administrator, director,
or consultant) who directly or indirectly manages, advises,
or supervises any element of the practices, finances, or
operations of the facility.
``(D) Organizational structure.--The term `organizational
structure' means, in the case of--
``(i) a corporation, the officers, directors, and
shareholders of the corporation who have an ownership
interest in the corporation which is equal to or exceeds 5
percent;
``(ii) a limited liability company, the members and
managers of the limited liability company (including, as
applicable, what percentage each member and manager has of
the ownership interest in the limited liability company);
``(iii) a general partnership, the partners of the general
partnership;
``(iv) a limited partnership, the general partners and any
limited partners of the limited partnership who have an
ownership interest in the limited partnership which is equal
to or exceeds 10 percent;
``(v) a trust, the trustees of the trust;
``(vi) an individual, contact information for the
individual; and
``(vii) any other person or entity, such information as the
Secretary determines appropriate.''.
(b) Public Availability of Information.--Not later than the
date that is 1 year after the date on which the final
regulations promulgated under section 1124(c)(3)(A) of the
Social Security Act, as added by subsection (a), are
published in the Federal Register, the Secretary of Health
and Human Services shall make the information reported in
accordance with such final regulations available to the
public in accordance with procedures established by the
Secretary.
(c) Conforming Amendments.--
(1) In general.--
(A) Skilled nursing facilities.--Section 1819(d)(1) of the
Social Security Act (42 U.S.C. 1395i-3(d)(1)) is amended by
striking subparagraph (B) and redesignating subparagraph (C)
as subparagraph (B).
(B) Nursing facilities.--Section 1919(d)(1) of the Social
Security Act (42 U.S.C. 1396r(d)(1)) is amended by striking
subparagraph (B) and redesignating subparagraph (C) as
subparagraph (B).
(2) Effective date.--The amendments made by paragraph (1)
shall take effect on the date on which the Secretary makes
the information described in subsection (b)(1) available to
the public under such subsection.
SEC. 6102. ACCOUNTABILITY REQUIREMENTS FOR SKILLED NURSING
FACILITIES AND NURSING FACILITIES.
Part A of title XI of the Social Security Act (42 U.S.C.
1301 et seq.), as amended by sections 6002 and 6004, is
amended by inserting after section 1128H the following new
section:
``SEC. 1128I. ACCOUNTABILITY REQUIREMENTS FOR FACILITIES.
``(a) Definition of Facility.--In this section, the term
`facility' means--
``(1) a skilled nursing facility (as defined in section
1819(a)); or
``(2) a nursing facility (as defined in section 1919(a)).
``(b) Effective Compliance and Ethics Programs.--
``(1) Requirement.--On or after the date that is 36 months
after the date of the enactment of this section, a facility
shall, with respect to the entity that operates the facility
(in this subparagraph referred to as the `operating
organization' or `organization'), have in operation a
compliance and ethics program that is effective in preventing
and detecting criminal, civil, and administrative violations
under this Act and in promoting quality of care consistent
with regulations developed under paragraph (2).
``(2) Development of regulations.--
``(A) In general.--Not later than the date that is 2 years
after such date of the enactment, the Secretary, working
jointly with the Inspector General of the Department of
Health and Human Services, shall promulgate regulations for
an effective compliance and ethics program for operating
organizations, which may include a model compliance program.
``(B) Design of regulations.--Such regulations with
respect to specific elements or formality of a program shall,
in the case of an organization that operates 5 or more
facilities, vary with the size of the organization, such that
larger organizations should have a more formal program and
include established written policies defining the standards
and procedures to be followed by its employees. Such
requirements may specifically apply to the corporate level
management of multi unit nursing home chains.
``(C) Evaluation.--Not later than 3 years after the date of
the promulgation of regulations under this paragraph, the
Secretary shall complete an evaluation of the compliance and
ethics programs required to be established under this
subsection. Such evaluation shall determine if such programs
led to changes in deficiency citations, changes in quality
performance, or changes in other metrics of patient quality
of care. The Secretary shall submit to Congress a report on
such evaluation and shall include in such report such
recommendations regarding changes in the requirements for
such programs as the Secretary determines appropriate.
``(3) Requirements for compliance and ethics programs.--In
this subsection, the term `compliance and ethics program'
means, with respect to a facility, a program of the operating
organization that--
``(A) has been reasonably designed, implemented, and
enforced so that it generally will be effective in preventing
and detecting criminal, civil, and administrative violations
under this Act and in promoting quality of care; and
``(B) includes at least the required components specified
in paragraph (4).
``(4) Required components of program.--The required
components of a compliance and ethics program of an operating
organization are the following:
``(A) The organization must have established compliance
standards and procedures to be followed by its employees and
other agents that are reasonably capable of reducing the
prospect of criminal, civil, and administrative violations
under this Act.
``(B) Specific individuals within high-level personnel of
the organization must have been
[[Page H2071]]
assigned overall responsibility to oversee compliance with
such standards and procedures and have sufficient resources
and authority to assure such compliance.
``(C) The organization must have used due care not to
delegate substantial discretionary authority to individuals
whom the organization knew, or should have known through the
exercise of due diligence, had a propensity to engage in
criminal, civil, and administrative violations under this
Act.
``(D) The organization must have taken steps to communicate
effectively its standards and procedures to all employees and
other agents, such as by requiring participation in training
programs or by disseminating publications that explain in a
practical manner what is required.
``(E) The organization must have taken reasonable steps to
achieve compliance with its standards, such as by utilizing
monitoring and auditing systems reasonably designed to detect
criminal, civil, and administrative violations under this Act
by its employees and other agents and by having in place and
publicizing a reporting system whereby employees and other
agents could report violations by others within the
organization without fear of retribution.
``(F) The standards must have been consistently enforced
through appropriate disciplinary mechanisms, including, as
appropriate, discipline of individuals responsible for the
failure to detect an offense.
``(G) After an offense has been detected, the organization
must have taken all reasonable steps to respond appropriately
to the offense and to prevent further similar offenses,
including any necessary modification to its program to
prevent and detect criminal, civil, and administrative
violations under this Act.
``(H) The organization must periodically undertake
reassessment of its compliance program to identify changes
necessary to reflect changes within the organization and its
facilities.
``(c) Quality Assurance and Performance Improvement
Program.--
``(1) In general.--Not later than December 31, 2011, the
Secretary shall establish and implement a quality assurance
and performance improvement program (in this subparagraph
referred to as the `QAPI program') for facilities, including
multi unit chains of facilities. Under the QAPI program, the
Secretary shall establish standards relating to quality
assurance and performance improvement with respect to
facilities and provide technical assistance to facilities on
the development of best practices in order to meet such
standards. Not later than 1 year after the date on which the
regulations are promulgated under paragraph (2), a facility
must submit to the Secretary a plan for the facility to meet
such standards and implement such best practices, including
how to coordinate the implementation of such plan with
quality assessment and assurance activities conducted under
sections 1819(b)(1)(B) and 1919(b)(1)(B), as applicable.
``(2) Regulations.--The Secretary shall promulgate
regulations to carry out this subsection.''.
SEC. 6103. NURSING HOME COMPARE MEDICARE WEBSITE.
(a) Skilled Nursing Facilities.--
(1) In general.--Section 1819 of the Social Security Act
(42 U.S.C. 1395i-3) is amended--
(A) by redesignating subsection (i) as subsection (j); and
(B) by inserting after subsection (h) the following new
subsection:
``(i) Nursing Home Compare Website.--
``(1) Inclusion of additional information.--
``(A) In general.--The Secretary shall ensure that the
Department of Health and Human Services includes, as part of
the information provided for comparison of nursing homes on
the official Internet website of the Federal Government for
Medicare beneficiaries (commonly referred to as the `Nursing
Home Compare' Medicare website) (or a successor website), the
following information in a manner that is prominent, updated
on a timely basis, easily accessible, readily understandable
to consumers of long-term care services, and searchable:
``(i) Staffing data for each facility (including resident
census data and data on the hours of care provided per
resident per day) based on data submitted under section
1128I(g), including information on staffing turnover and
tenure, in a format that is clearly understandable to
consumers of long-term care services and allows such
consumers to compare differences in staffing between
facilities and State and national averages for the
facilities. Such format shall include--
``(I) concise explanations of how to interpret the data
(such as a plain English explanation of data reflecting
`nursing home staff hours per resident day');
``(II) differences in types of staff (such as training
associated with different categories of staff);
``(III) the relationship between nurse staffing levels and
quality of care; and
``(IV) an explanation that appropriate staffing levels vary
based on patient case mix.
``(ii) Links to State Internet websites with information
regarding State survey and certification programs, links to
Form 2567 State inspection reports (or a successor form) on
such websites, information to guide consumers in how to
interpret and understand such reports, and the facility plan
of correction or other response to such report. Any such
links shall be posted on a timely basis.
``(iii) The standardized complaint form developed under
section 1128I(f), including explanatory material on what
complaint forms are, how they are used, and how to file a
complaint with the State survey and certification program and
the State long-term care ombudsman program.
``(iv) Summary information on the number, type, severity,
and outcome of substantiated complaints.
``(v) The number of adjudicated instances of criminal
violations by a facility or the employees of a facility--
``(I) that were committed inside the facility;
``(II) with respect to such instances of violations or
crimes committed inside of the facility that were the
violations or crimes of abuse, neglect, and exploitation,
criminal sexual abuse, or other violations or crimes that
resulted in serious bodily injury; and
``(III) the number of civil monetary penalties levied
against the facility, employees, contractors, and other
agents.
``(B) Deadline for provision of information.--
``(i) In general.--Except as provided in clause (ii), the
Secretary shall ensure that the information described in
subparagraph (A) is included on such website (or a successor
website) not later than 1 year after the date of the
enactment of this subsection.
``(ii) Exception.--The Secretary shall ensure that the
information described in subparagraph (A)(i) is included on
such website (or a successor website) not later than the date
on which the requirements under section 1128I(g) are
implemented.
``(2) Review and modification of website.--
``(A) In general.--The Secretary shall establish a
process--
``(i) to review the accuracy, clarity of presentation,
timeliness, and comprehensiveness of information reported on
such website as of the day before the date of the enactment
of this subsection; and
``(ii) not later than 1 year after the date of the
enactment of this subsection, to modify or revamp such
website in accordance with the review conducted under clause
(i).
``(B) Consultation.--In conducting the review under
subparagraph (A)(i), the Secretary shall consult with--
``(i) State long-term care ombudsman programs;
``(ii) consumer advocacy groups;
``(iii) provider stakeholder groups; and
``(iv) any other representatives of programs or groups the
Secretary determines appropriate.''.
(2) Timeliness of submission of survey and certification
information.--
(A) In general.--Section 1819(g)(5) of the Social Security
Act (42 U.S.C. 1395i-3(g)(5)) is amended by adding at the end
the following new subparagraph:
``(E) Submission of survey and certification information to
the secretary.--In order to improve the timeliness of
information made available to the public under subparagraph
(A) and provided on the Nursing Home Compare Medicare website
under subsection (i), each State shall submit information
respecting any survey or certification made respecting a
skilled nursing facility (including any enforcement actions
taken by the State) to the Secretary not later than the date
on which the State sends such information to the facility.
The Secretary shall use the information submitted under the
preceding sentence to update the information provided on the
Nursing Home Compare Medicare website as expeditiously as
practicable but not less frequently than quarterly.''.
(B) Effective date.--The amendment made by this paragraph
shall take effect 1 year after the date of the enactment of
this Act.
(3) Special focus facility program.--Section 1819(f) of the
Social Security Act (42 U.S.C. 1395i-3(f)) is amended by
adding at the end the following new paragraph:
``(8) Special focus facility program.--
``(A) In general.--The Secretary shall conduct a special
focus facility program for enforcement of requirements for
skilled nursing facilities that the Secretary has identified
as having substantially failed to meet applicable requirement
of this Act.
``(B) Periodic surveys.--Under such program the Secretary
shall conduct surveys of each facility in the program not
less than once every 6 months.''.
(b) Nursing Facilities.--
(1) In general.--Section 1919 of the Social Security Act
(42 U.S.C. 1396r) is amended--
(A) by redesignating subsection (i) as subsection (j); and
(B) by inserting after subsection (h) the following new
subsection:
``(i) Nursing Home Compare Website.--
``(1) Inclusion of additional information.--
``(A) In general.--The Secretary shall ensure that the
Department of Health and Human Services includes, as part of
the information provided for comparison of nursing homes on
the official Internet website of the Federal Government for
Medicare beneficiaries (commonly referred to as the `Nursing
Home Compare' Medicare website) (or a successor website), the
following information in a manner that is prominent, updated
on a timely basis, easily accessible, readily understandable
to consumers of long-term care services, and searchable:
``(i) Staffing data for each facility (including resident
census data and data on the hours of care provided per
resident per day) based on data submitted under section
1128I(g), including information on staffing turnover and
tenure, in a format that is clearly understandable to
consumers of long-term care services and allows such
consumers to compare differences in staffing between
facilities and State and national averages for the
facilities. Such format shall include--
``(I) concise explanations of how to interpret the data
(such as plain English explanation of data reflecting
`nursing home staff hours per resident day');
``(II) differences in types of staff (such as training
associated with different categories of staff);
``(III) the relationship between nurse staffing levels and
quality of care; and
``(IV) an explanation that appropriate staffing levels vary
based on patient case mix.
[[Page H2072]]
``(ii) Links to State Internet websites with information
regarding State survey and certification programs, links to
Form 2567 State inspection reports (or a successor form) on
such websites, information to guide consumers in how to
interpret and understand such reports, and the facility plan
of correction or other response to such report. Any such
links shall be posted on a timely basis.
``(iii) The standardized complaint form developed under
section 1128I(f), including explanatory material on what
complaint forms are, how they are used, and how to file a
complaint with the State survey and certification program and
the State long-term care ombudsman program.
``(iv) Summary information on the number, type, severity,
and outcome of substantiated complaints.
``(v) The number of adjudicated instances of criminal
violations by a facility or the employees of a facility--
``(I) that were committed inside of the facility; and
``(II) with respect to such instances of violations or
crimes committed outside of the facility, that were
violations or crimes that resulted in the serious bodily
injury of an elder.
``(B) Deadline for provision of information.--
``(i) In general.--Except as provided in clause (ii), the
Secretary shall ensure that the information described in
subparagraph (A) is included on such website (or a successor
website) not later than 1 year after the date of the
enactment of this subsection.
``(ii) Exception.--The Secretary shall ensure that the
information described in subparagraph (A)(i) is included on
such website (or a successor website) not later than the date
on which the requirements under section 1128I(g) are
implemented.
``(2) Review and modification of website.--
``(A) In general.--The Secretary shall establish a
process--
``(i) to review the accuracy, clarity of presentation,
timeliness, and comprehensiveness of information reported on
such website as of the day before the date of the enactment
of this subsection; and
``(ii) not later than 1 year after the date of the
enactment of this subsection, to modify or revamp such
website in accordance with the review conducted under clause
(i).
``(B) Consultation.--In conducting the review under
subparagraph (A)(i), the Secretary shall consult with--
``(i) State long-term care ombudsman programs;
``(ii) consumer advocacy groups;
``(iii) provider stakeholder groups;
``(iv) skilled nursing facility employees and their
representatives; and
``(v) any other representatives of programs or groups the
Secretary determines appropriate.''.
(2) Timeliness of submission of survey and certification
information.--
(A) In general.--Section 1919(g)(5) of the Social Security
Act (42 U.S.C. 1396r(g)(5)) is amended by adding at the end
the following new subparagraph:
``(E) Submission of survey and certification information to
the secretary.--In order to improve the timeliness of
information made available to the public under subparagraph
(A) and provided on the Nursing Home Compare Medicare website
under subsection (i), each State shall submit information
respecting any survey or certification made respecting a
nursing facility (including any enforcement actions taken by
the State) to the Secretary not later than the date on which
the State sends such information to the facility. The
Secretary shall use the information submitted under the
preceding sentence to update the information provided on the
Nursing Home Compare Medicare website as expeditiously as
practicable but not less frequently than quarterly.''.
(B) Effective date.--The amendment made by this paragraph
shall take effect 1 year after the date of the enactment of
this Act.
(3) Special focus facility program.--Section 1919(f) of the
Social Security Act (42 U.S.C. 1396r(f)) is amended by adding
at the end of the following new paragraph:
``(10) Special focus facility program.--
``(A) In general.--The Secretary shall conduct a special
focus facility program for enforcement of requirements for
nursing facilities that the Secretary has identified as
having substantially failed to meet applicable requirements
of this Act.
``(B) Periodic surveys.--Under such program the Secretary
shall conduct surveys of each facility in the program not
less often than once every 6 months.''.
(c) Availability of Reports on Surveys, Certifications, and
Complaint Investigations.--
(1) Skilled nursing facilities.--Section 1819(d)(1) of the
Social Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by
section 6101, is amended by adding at the end the following
new subparagraph:
``(C) Availability of survey, certification, and complaint
investigation reports.--A skilled nursing facility must--
``(i) have reports with respect to any surveys,
certifications, and complaint investigations made respecting
the facility during the 3 preceding years available for any
individual to review upon request; and
``(ii) post notice of the availability of such reports in
areas of the facility that are prominent and accessible to
the public.
The facility shall not make available under clause (i)
identifying information about complainants or residents.''.
(2) Nursing facilities.--Section 1919(d)(1) of the Social
Security Act (42 U.S.C. 1396r(d)(1)), as amended by section
6101, is amended by adding at the end the following new
subparagraph:
``(V) Availability of survey, certification, and complaint
investigation reports.--A nursing facility must--
``(i) have reports with respect to any surveys,
certifications, and complaint investigations made respecting
the facility during the 3 preceding years available for any
individual to review upon request; and
``(ii) post notice of the availability of such reports in
areas of the facility that are prominent and accessible to
the public.
The facility shall not make available under clause (i)
identifying information about complainants or residents.''.
(3) Effective date.--The amendments made by this subsection
shall take effect 1 year after the date of the enactment of
this Act.
(d) Guidance to States on Form 2567 State Inspection
Reports and Complaint Investigation Reports.--
(1) Guidance.--The Secretary of Health and Human Services
(in this subtitle referred to as the ``Secretary'') shall
provide guidance to States on how States can establish
electronic links to Form 2567 State inspection reports (or a
successor form), complaint investigation reports, and a
facility's plan of correction or other response to such Form
2567 State inspection reports (or a successor form) on the
Internet website of the State that provides information on
skilled nursing facilities and nursing facilities and the
Secretary shall, if possible, include such information on
Nursing Home Compare.
(2) Requirement.--Section 1902(a)(9) of the Social Security
Act (42 U.S.C. 1396a(a)(9)) is amended--
(A) by striking ``and'' at the end of subparagraph (B);
(B) by striking the semicolon at the end of subparagraph
(C) and inserting ``, and''; and
(C) by adding at the end the following new subparagraph:
``(D) that the State maintain a consumer-oriented website
providing useful information to consumers regarding all
skilled nursing facilities and all nursing facilities in the
State, including for each facility, Form 2567 State
inspection reports (or a successor form), complaint
investigation reports, the facility's plan of correction, and
such other information that the State or the Secretary
considers useful in assisting the public to assess the
quality of long term care options and the quality of care
provided by individual facilities;''.
(3) Definitions.--In this subsection:
(A) Nursing facility.--The term ``nursing facility'' has
the meaning given such term in section 1919(a) of the Social
Security Act (42 U.S.C. 1396r(a)).
(B) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(C) Skilled nursing facility.--The term ``skilled nursing
facility'' has the meaning given such term in section 1819(a)
of the Social Security Act (42 U.S.C. 1395i-3(a)).
(e) Development of Consumer Rights Information Page on
Nursing Home Compare Website.--Not later than 1 year after
the date of enactment of this Act, the Secretary shall ensure
that the Department of Health and Human Services, as part of
the information provided for comparison of nursing facilities
on the Nursing Home Compare Medicare website develops and
includes a consumer rights information page that contains
links to descriptions of, and information with respect to,
the following:
(1) The documentation on nursing facilities that is
available to the public.
(2) General information and tips on choosing a nursing
facility that meets the needs of the individual.
(3) General information on consumer rights with respect to
nursing facilities.
(4) The nursing facility survey process (on a national and
State-specific basis).
(5) On a State-specific basis, the services available
through the State long-term care ombudsman for such State.
SEC. 6104. REPORTING OF EXPENDITURES.
Section 1888 of the Social Security Act (42 U.S.C. 1395yy)
is amended by adding at the end the following new subsection:
``(f) Reporting of Direct Care Expenditures.--
``(1) In general.--For cost reports submitted under this
title for cost reporting periods beginning on or after the
date that is 2 years after the date of the enactment of this
subsection, skilled nursing facilities shall separately
report expenditures for wages and benefits for direct care
staff (breaking out (at a minimum) registered nurses,
licensed professional nurses, certified nurse assistants, and
other medical and therapy staff).
``(2) Modification of form.--The Secretary, in consultation
with private sector accountants experienced with Medicare and
Medicaid nursing facility home cost reports, shall redesign
such reports to meet the requirement of paragraph (1) not
later than 1 year after the date of the enactment of this
subsection.
``(3) Categorization by functional accounts.--Not later
than 30 months after the date of the enactment of this
subsection, the Secretary, working in consultation with the
Medicare Payment Advisory Commission, the Medicaid and CHIP
Payment and Access Commission, the Inspector General of the
Department of Health and Human Services, and other expert
parties the Secretary determines appropriate, shall take the
expenditures listed on cost reports, as modified under
paragraph (1), submitted by skilled nursing facilities and
categorize such expenditures, regardless of any source of
payment for such expenditures, for each skilled nursing
facility into the following functional accounts on an annual
basis:
``(A) Spending on direct care services (including nursing,
therapy, and medical services).
``(B) Spending on indirect care (including housekeeping and
dietary services).
``(C) Capital assets (including building and land costs).
[[Page H2073]]
``(D) Administrative services costs.
``(4) Availability of information submitted.--The Secretary
shall establish procedures to make information on
expenditures submitted under this subsection readily
available to interested parties upon request, subject to such
requirements as the Secretary may specify under the
procedures established under this paragraph.''.
SEC. 6105. STANDARDIZED COMPLAINT FORM.
(a) In General.--Section 1128I of the Social Security Act,
as added and amended by this Act, is amended by adding at the
end the following new subsection:
``(f) Standardized Complaint Form.--
``(1) Development by the secretary.--The Secretary shall
develop a standardized complaint form for use by a resident
(or a person acting on the resident's behalf) in filing a
complaint with a State survey and certification agency and a
State long-term care ombudsman program with respect to a
facility.
``(2) Complaint forms and resolution processes.--
``(A) Complaint forms.--The State must make the
standardized complaint form developed under paragraph (1)
available upon request to--
``(i) a resident of a facility; and
``(ii) any person acting on the resident's behalf.
``(B) Complaint resolution process.--The State must
establish a complaint resolution process in order to ensure
that the legal representative of a resident of a facility or
other responsible party is not denied access to such resident
or otherwise retaliated against if they have complained about
the quality of care provided by the facility or other issues
relating to the facility. Such complaint resolution process
shall include--
``(i) procedures to assure accurate tracking of complaints
received, including notification to the complainant that a
complaint has been received;
``(ii) procedures to determine the likely severity of a
complaint and for the investigation of the complaint; and
``(iii) deadlines for responding to a complaint and for
notifying the complainant of the outcome of the
investigation.
``(3) Rule of construction.--Nothing in this subsection
shall be construed as preventing a resident of a facility (or
a person acting on the resident's behalf) from submitting a
complaint in a manner or format other than by using the
standardized complaint form developed under paragraph (1)
(including submitting a complaint orally).''.
(b) Effective Date.--The amendment made by this section
shall take effect 1 year after the date of the enactment of
this Act.
SEC. 6106. ENSURING STAFFING ACCOUNTABILITY.
Section 1128I of the Social Security Act, as added and
amended by this Act, is amended by adding at the end the
following new subsection:
``(g) Submission of Staffing Information Based on Payroll
Data in a Uniform Format.--Beginning not later than 2 years
after the date of the enactment of this subsection, and after
consulting with State long-term care ombudsman programs,
consumer advocacy groups, provider stakeholder groups,
employees and their representatives, and other parties the
Secretary deems appropriate, the Secretary shall require a
facility to electronically submit to the Secretary direct
care staffing information (including information with respect
to agency and contract staff) based on payroll and other
verifiable and auditable data in a uniform format (according
to specifications established by the Secretary in
consultation with such programs, groups, and parties). Such
specifications shall require that the information submitted
under the preceding sentence--
``(1) specify the category of work a certified employee
performs (such as whether the employee is a registered nurse,
licensed practical nurse, licensed vocational nurse,
certified nursing assistant, therapist, or other medical
personnel);
``(2) include resident census data and information on
resident case mix;
``(3) include a regular reporting schedule; and
``(4) include information on employee turnover and tenure
and on the hours of care provided by each category of
certified employees referenced in paragraph (1) per resident
per day.
Nothing in this subsection shall be construed as preventing
the Secretary from requiring submission of such information
with respect to specific categories, such as nursing staff,
before other categories of certified employees. Information
under this subsection with respect to agency and contract
staff shall be kept separate from information on employee
staffing.''.
SEC. 6107. GAO STUDY AND REPORT ON FIVE-STAR QUALITY RATING
SYSTEM.
(a) Study.--The Comptroller General of the United States
(in this section referred to as the ``Comptroller General'')
shall conduct a study on the Five-Star Quality Rating System
for nursing homes of the Centers for Medicare & Medicaid
Services. Such study shall include an analysis of--
(1) how such system is being implemented;
(2) any problems associated with such system or its
implementation; and
(3) how such system could be improved.
(b) Report.--Not later than 2 years after the date of
enactment of this Act, the Comptroller General shall submit
to Congress a report containing the results of the study
conducted under subsection (a), together with recommendations
for such legislation and administrative action as the
Comptroller General determines appropriate.
PART II--TARGETING ENFORCEMENT
SEC. 6111. CIVIL MONEY PENALTIES.
(a) Skilled Nursing Facilities.--
(1) In general.--Section 1819(h)(2)(B)(ii) of the Social
Security Act (42 U.S.C. 1395i-3(h)(2)(B)(ii)) is amended--
(A) by striking ``Penalties.--The Secretary'' and inserting
``penalties.--
``(I) In general.--Subject to subclause (II), the
Secretary''; and
(B) by adding at the end the following new subclauses:
``(II) Reduction of civil money penalties in certain
circumstances.--Subject to subclause (III), in the case where
a facility self-reports and promptly corrects a deficiency
for which a penalty was imposed under this clause not later
than 10 calendar days after the date of such imposition, the
Secretary may reduce the amount of the penalty imposed by not
more than 50 percent.
``(III) Prohibitions on reduction for certain
deficiencies.--
``(aa) Repeat deficiencies.--The Secretary may not reduce
the amount of a penalty under subclause (II) if the Secretary
had reduced a penalty imposed on the facility in the
preceding year under such subclause with respect to a repeat
deficiency.
``(bb) Certain other deficiencies.--The Secretary may not
reduce the amount of a penalty under subclause (II) if the
penalty is imposed on the facility for a deficiency that is
found to result in a pattern of harm or widespread harm,
immediately jeopardizes the health or safety of a resident or
residents of the facility, or results in the death of a
resident of the facility.
``(IV) Collection of civil money penalties.--In the case of
a civil money penalty imposed under this clause, the
Secretary shall issue regulations that--
``(aa) subject to item (cc), not later than 30 days after
the imposition of the penalty, provide for the facility to
have the opportunity to participate in an independent
informal dispute resolution process which generates a written
record prior to the collection of such penalty;
``(bb) in the case where the penalty is imposed for each
day of noncompliance, provide that a penalty may not be
imposed for any day during the period beginning on the
initial day of the imposition of the penalty and ending on
the day on which the informal dispute resolution process
under item (aa) is completed;
``(cc) may provide for the collection of such civil money
penalty and the placement of such amounts collected in an
escrow account under the direction of the Secretary on the
earlier of the date on which the informal dispute resolution
process under item (aa) is completed or the date that is 90
days after the date of the imposition of the penalty;
``(dd) may provide that such amounts collected are kept in
such account pending the resolution of any subsequent
appeals;
``(ee) in the case where the facility successfully appeals
the penalty, may provide for the return of such amounts
collected (plus interest) to the facility; and
``(ff) in the case where all such appeals are unsuccessful,
may provide that some portion of such amounts collected may
be used to support activities that benefit residents,
including assistance to support and protect residents of a
facility that closes (voluntarily or involuntarily) or is
decertified (including offsetting costs of relocating
residents to home and community-based settings or another
facility), projects that support resident and family councils
and other consumer involvement in assuring quality care in
facilities, and facility improvement initiatives approved by
the Secretary (including joint training of facility staff and
surveyors, technical assistance for facilities implementing
quality assurance programs, the appointment of temporary
management firms, and other activities approved by the
Secretary).''.
(2) Conforming amendment.--The second sentence of section
1819(h)(5) of the Social Security Act (42 U.S.C. 1395i-
3(h)(5)) is amended by inserting ``(ii)(IV),'' after
``(i),''.
(b) Nursing Facilities.--
(1) In general.--Section 1919(h)(3)(C)(ii) of the Social
Security Act (42 U.S.C. 1396r(h)(3)(C)) is amended--
(A) by striking ``Penalties.--The Secretary'' and inserting
``penalties.--
``(I) In general.--Subject to subclause (II), the
Secretary''; and
(B) by adding at the end the following new subclauses:
``(II) Reduction of civil money penalties in certain
circumstances.--Subject to subclause (III), in the case where
a facility self-reports and promptly corrects a deficiency
for which a penalty was imposed under this clause not later
than 10 calendar days after the date of such imposition, the
Secretary may reduce the amount of the penalty imposed by not
more than 50 percent.
``(III) Prohibitions on reduction for certain
deficiencies.--
``(aa) Repeat deficiencies.--The Secretary may not reduce
the amount of a penalty under subclause (II) if the Secretary
had reduced a penalty imposed on the facility in the
preceding year under such subclause with respect to a repeat
deficiency.
``(bb) Certain other deficiencies.--The Secretary may not
reduce the amount of a penalty under subclause (II) if the
penalty is imposed on the facility for a deficiency that is
found to result in a pattern of harm or widespread harm,
immediately jeopardizes the health or safety of a resident or
residents of the facility, or results in the death of a
resident of the facility.
``(IV) Collection of civil money penalties.--In the case of
a civil money penalty imposed under this clause, the
Secretary shall issue regulations that--
``(aa) subject to item (cc), not later than 30 days after
the imposition of the penalty, provide for the facility to
have the opportunity to participate in an independent
informal dispute resolution process which generates a written
record prior to the collection of such penalty;
``(bb) in the case where the penalty is imposed for each
day of noncompliance, provide that a
[[Page H2074]]
penalty may not be imposed for any day during the period
beginning on the initial day of the imposition of the penalty
and ending on the day on which the informal dispute
resolution process under item (aa) is completed;
``(cc) may provide for the collection of such civil money
penalty and the placement of such amounts collected in an
escrow account under the direction of the Secretary on the
earlier of the date on which the informal dispute resolution
process under item (aa) is completed or the date that is 90
days after the date of the imposition of the penalty;
``(dd) may provide that such amounts collected are kept in
such account pending the resolution of any subsequent
appeals;
``(ee) in the case where the facility successfully appeals
the penalty, may provide for the return of such amounts
collected (plus interest) to the facility; and
``(ff) in the case where all such appeals are unsuccessful,
may provide that some portion of such amounts collected may
be used to support activities that benefit residents,
including assistance to support and protect residents of a
facility that closes (voluntarily or involuntarily) or is
decertified (including offsetting costs of relocating
residents to home and community-based settings or another
facility), projects that support resident and family councils
and other consumer involvement in assuring quality care in
facilities, and facility improvement initiatives approved by
the Secretary (including joint training of facility staff and
surveyors, technical assistance for facilities implementing
quality assurance programs, the appointment of temporary
management firms, and other activities approved by the
Secretary).''.
(2) Conforming amendment.--Section 1919(h)(5)(8) of the
Social Security Act (42 U.S.C. 1396r(h)(5)(8)) is amended by
inserting ``(ii)(IV),'' after ``(i),''.
(c) Effective Date.--The amendments made by this section
shall take effect 1 year after the date of the enactment of
this Act.
SEC. 6112. NATIONAL INDEPENDENT MONITOR DEMONSTRATION
PROJECT.
(a) Establishment.--
(1) In general.--The Secretary, in consultation with the
Inspector General of the Department of Health and Human
Services, shall conduct a demonstration project to develop,
test, and implement an independent monitor program to oversee
interstate and large intrastate chains of skilled nursing
facilities and nursing facilities.
(2) Selection.--The Secretary shall select chains of
skilled nursing facilities and nursing facilities described
in paragraph (1) to participate in the demonstration project
under this section from among those chains that submit an
application to the Secretary at such time, in such manner,
and containing such information as the Secretary may require.
(3) Duration.--The Secretary shall conduct the
demonstration project under this section for a 2-year period.
(4) Implementation.--The Secretary shall implement the
demonstration project under this section not later than 1
year after the date of the enactment of this Act.
(b) Requirements.--The Secretary shall evaluate chains
selected to participate in the demonstration project under
this section based on criteria selected by the Secretary,
including where evidence suggests that a number of the
facilities of the chain are experiencing serious safety and
quality of care problems. Such criteria may include the
evaluation of a chain that includes a number of facilities
participating in the ``Special Focus Facility'' program (or a
successor program) or multiple facilities with a record of
repeated serious safety and quality of care deficiencies.
(c) Responsibilities.--An independent monitor that enters
into a contract with the Secretary to participate in the
conduct of the demonstration project under this section
shall--
(1) conduct periodic reviews and prepare root-cause quality
and deficiency analyses of a chain to assess if facilities of
the chain are in compliance with State and Federal laws and
regulations applicable to the facilities;
(2) conduct sustained oversight of the efforts of the
chain, whether publicly or privately held, to achieve
compliance by facilities of the chain with State and Federal
laws and regulations applicable to the facilities;
(3) analyze the management structure, distribution of
expenditures, and nurse staffing levels of facilities of the
chain in relation to resident census, staff turnover rates,
and tenure;
(4) report findings and recommendations with respect to
such reviews, analyses, and oversight to the chain and
facilities of the chain, to the Secretary, and to relevant
States; and
(5) publish the results of such reviews, analyses, and
oversight.
(d) Implementation of Recommendations.--
(1) Receipt of finding by chain.--Not later than 10 days
after receipt of a finding of an independent monitor under
subsection (c)(4), a chain participating in the demonstration
project shall submit to the independent monitor a report--
(A) outlining corrective actions the chain will take to
implement the recommendations in such report; or
(B) indicating that the chain will not implement such
recommendations, and why it will not do so.
(2) Receipt of report by independent monitor.--Not later
than 10 days after receipt of a report submitted by a chain
under paragraph (1), an independent monitor shall finalize
its recommendations and submit a report to the chain and
facilities of the chain, the Secretary, and the State or
States, as appropriate, containing such final
recommendations.
(e) Cost of Appointment.--A chain shall be responsible for
a portion of the costs associated with the appointment of
independent monitors under the demonstration project under
this section. The chain shall pay such portion to the
Secretary (in an amount and in accordance with procedures
established by the Secretary).
(f) Waiver Authority.--The Secretary may waive such
requirements of titles XVIII and XIX of the Social Security
Act (42 U.S.C. 1395 et seq.; 1396 et seq.) as may be
necessary for the purpose of carrying out the demonstration
project under this section.
(g) Authorization of Appropriations.--There are authorized
to be appropriated such sums as may be necessary to carry out
this section.
(h) Definitions.--In this section:
(1) Additional disclosable party.--The term ``additional
disclosable party'' has the meaning given such term in
section 1124(c)(5)(A) of the Social Security Act, as added by
section 4201(a).
(2) Facility.--The term ``facility'' means a skilled
nursing facility or a nursing facility.
(3) Nursing facility.--The term ``nursing facility'' has
the meaning given such term in section 1919(a) of the Social
Security Act (42 U.S.C. 1396r(a)).
(4) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services, acting through the Assistant
Secretary for Planning and Evaluation.
(5) Skilled nursing facility.--The term ``skilled nursing
facility'' has the meaning given such term in section 1819(a)
of the Social Security Act (42 U.S.C. 1395(a)).
(i) Evaluation and Report.--
(1) Evaluation.--The Secretary, in consultation with the
Inspector General of the Department of Health and Human
Services, shall evaluate the demonstration project conducted
under this section.
(2) Report.--Not later than 180 days after the completion
of the demonstration project under this section, the
Secretary shall submit to Congress a report containing the
results of the evaluation conducted under paragraph (1),
together with recommendations--
(A) as to whether the independent monitor program should be
established on a permanent basis;
(B) if the Secretary recommends that such program be so
established, on appropriate procedures and mechanisms for
such establishment; and
(C) for such legislation and administrative action as the
Secretary determines appropriate.
SEC. 6113. NOTIFICATION OF FACILITY CLOSURE.
(a) In General.--Section 1128I of the Social Security Act,
as added and amended by this Act, is amended by adding at the
end the following new subsection:
``(h) Notification of Facility Closure.--
``(1) In general.--Any individual who is the administrator
of a facility must--
``(A) submit to the Secretary, the State long-term care
ombudsman, residents of the facility, and the legal
representatives of such residents or other responsible
parties, written notification of an impending closure--
``(i) subject to clause (ii), not later than the date that
is 60 days prior to the date of such closure; and
``(ii) in the case of a facility where the Secretary
terminates the facility's participation under this title, not
later than the date that the Secretary determines
appropriate;
``(B) ensure that the facility does not admit any new
residents on or after the date on which such written
notification is submitted; and
``(C) include in the notice a plan for the transfer and
adequate relocation of the residents of the facility by a
specified date prior to closure that has been approved by the
State, including assurances that the residents will be
transferred to the most appropriate facility or other setting
in terms of quality, services, and location, taking into
consideration the needs, choice, and best interests of each
resident.
``(2) Relocation.--
``(A) In general.--The State shall ensure that, before a
facility closes, all residents of the facility have been
successfully relocated to another facility or an alternative
home and community-based setting.
``(B) Continuation of payments until residents relocated.--
The Secretary may, as the Secretary determines appropriate,
continue to make payments under this title with respect to
residents of a facility that has submitted a notification
under paragraph (1) during the period beginning on the date
such notification is submitted and ending on the date on
which the resident is successfully relocated.
``(3) Sanctions.--Any individual who is the administrator
of a facility that fails to comply with the requirements of
paragraph (1)--
``(A) shall be subject to a civil monetary penalty of up to
$100,000;
``(B) may be subject to exclusion from participation in any
Federal health care program (as defined in section 1128B(f));
and
``(C) shall be subject to any other penalties that may be
prescribed by law.
``(4) Procedure.--The provisions of section 1128A (other
than subsections (a) and (b) and the second sentence of
subsection (f)) shall apply to a civil money penalty or
exclusion under paragraph (3) in the same manner as such
provisions apply to a penalty or proceeding under section
1128A(a).''.
(b) Conforming Amendments.--Section 1819(h)(4) of the
Social Security Act (42 U.S.C. 1395i-3(h)(4)) is amended--
(1) in the first sentence, by striking ``the Secretary
shall terminate'' and inserting ``the Secretary, subject to
section 1128I(h), shall terminate''; and
(2) in the second sentence, by striking ``subsection
(c)(2)'' and inserting ``subsection (c)(2) and section
1128I(h)''.
(c) Effective Date.--The amendments made by this section
shall take effect 1 year after the date of the enactment of
this Act.
[[Page H2075]]
SEC. 6114. NATIONAL DEMONSTRATION PROJECTS ON CULTURE CHANGE
AND USE OF INFORMATION TECHNOLOGY IN NURSING
HOMES.
(a) In General.--The Secretary shall conduct 2
demonstration projects, 1 for the development of best
practices in skilled nursing facilities and nursing
facilities that are involved in the culture change movement
(including the development of resources for facilities to
find and access funding in order to undertake culture change)
and 1 for the development of best practices in skilled
nursing facilities and nursing facilities for the use of
information technology to improve resident care.
(b) Conduct of Demonstration Projects.--
(1) Grant award.--Under each demonstration project
conducted under this section, the Secretary shall award 1 or
more grants to facility-based settings for the development of
best practices described in subsection (a) with respect to
the demonstration project involved. Such award shall be made
on a competitive basis and may be allocated in 1 lump-sum
payment.
(2) Consideration of special needs of residents.--Each
demonstration project conducted under this section shall take
into consideration the special needs of residents of skilled
nursing facilities and nursing facilities who have cognitive
impairment, including dementia.
(c) Duration and Implementation.--
(1) Duration.--The demonstration projects shall each be
conducted for a period not to exceed 3 years.
(2) Implementation.--The demonstration projects shall each
be implemented not later than 1 year after the date of the
enactment of this Act.
(d) Definitions.--In this section:
(1) Nursing facility.--The term ``nursing facility'' has
the meaning given such term in section 1919(a) of the Social
Security Act (42 U.S.C. 1396r(a)).
(2) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(3) Skilled nursing facility.--The term ``skilled nursing
facility'' has the meaning given such term in section 1819(a)
of the Social Security Act (42 U.S.C. 1395(a)).
(e) Authorization of Appropriations.--There are authorized
to be appropriated such sums as may be necessary to carry out
this section.
(f) Report.--Not later than 9 months after the completion
of the demonstration project, the Secretary shall submit to
Congress a report on such project, together with
recommendations for such legislation and administrative
action as the Secretary determines appropriate.
PART III--IMPROVING STAFF TRAINING
SEC. 6121. DEMENTIA AND ABUSE PREVENTION TRAINING.
(a) Skilled Nursing Facilities.--
(1) In general.--Section 1819(f)(2)(A)(i)(I) of the Social
Security Act (42 U.S.C. 1395i-3(f)(2)(A)(i)(I)) is amended by
inserting ``(including, in the case of initial training and,
if the Secretary determines appropriate, in the case of
ongoing training, dementia management training, and patient
abuse prevention training'' before ``, (II)''.
(2) Clarification of definition of nurse aide.--Section
1819(b)(5)(F) of the Social Security Act (42 U.S.C. 1395i-
3(b)(5)(F)) is amended by adding at the end the following
flush sentence:
``Such term includes an individual who provides such services
through an agency or under a contract with the facility.''.
(b) Nursing Facilities.--
(1) In general.--Section 1919(f)(2)(A)(i)(I) of the
Social Security Act (42 U.S.C. 1396r(f)(2)(A)(i)(I)) is
amended by inserting ``(including, in the case of initial
training and, if the Secretary determines appropriate, in the
case of ongoing training, dementia management training, and
patient abuse prevention training'' before ``, (II)''.
(2) Clarification of definition of nurse aide.--Section
1919(b)(5)(F) of the Social Security Act (42 U.S.C.
1396r(b)(5)(F)) is amended by adding at the end the following
flush sentence:
``Such term includes an individual who provides such services
through an agency or under a contract with the facility.''.
(c) Effective Date.--The amendments made by this section
shall take effect 1 year after the date of the enactment of
this Act.
Subtitle C--Nationwide Program for National and State Background Checks
on Direct Patient Access Employees of Long-term Care Facilities and
Providers
SEC. 6201. NATIONWIDE PROGRAM FOR NATIONAL AND STATE
BACKGROUND CHECKS ON DIRECT PATIENT ACCESS
EMPLOYEES OF LONG-TERM CARE FACILITIES AND
PROVIDERS.
(a) In General.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary''), shall
establish a program to identify efficient, effective, and
economical procedures for long term care facilities or
providers to conduct background checks on prospective direct
patient access employees on a nationwide basis (in this
subsection, such program shall be referred to as the
``nationwide program''). Except for the following
modifications, the Secretary shall carry out the nationwide
program under similar terms and conditions as the pilot
program under section 307 of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (Public Law 108-
173; 117 Stat. 2257), including the prohibition on hiring
abusive workers and the authorization of the imposition of
penalties by a participating State under subsection (b)(3)(A)
and (b)(6), respectively, of such section 307:
(1) Agreements.--
(A) Newly participating states.--The Secretary shall enter
into agreements with each State--
(i) that the Secretary has not entered into an agreement
with under subsection (c)(1) of such section 307;
(ii) that agrees to conduct background checks under the
nationwide program on a Statewide basis; and
(iii) that submits an application to the Secretary
containing such information and at such time as the Secretary
may specify.
(B) Certain previously participating states.--The Secretary
shall enter into agreements with each State--
(i) that the Secretary has entered into an agreement with
under such subsection (c)(1), but only in the case where such
agreement did not require the State to conduct background
checks under the program established under subsection (a) of
such section 307 on a Statewide basis;
(ii) that agrees to conduct background checks under the
nationwide program on a Statewide basis; and
(iii) that submits an application to the Secretary
containing such information and at such time as the Secretary
may specify.
(2) Nonapplication of selection criteria.--The selection
criteria required under subsection (c)(3)(B) of such section
307 shall not apply.
(3) Required fingerprint check as part of criminal history
background check.--The procedures established under
subsection (b)(1) of such section 307 shall--
(A) require that the long-term care facility or provider
(or the designated agent of the long-term care facility or
provider) obtain State and national criminal history
background checks on the prospective employee through such
means as the Secretary determines appropriate, efficient, and
effective that utilize a search of State-based abuse and
neglect registries and databases, including the abuse and
neglect registries of another State in the case where a
prospective employee previously resided in that State, State
criminal history records, the records of any proceedings in
the State that may contain disqualifying information about
prospective employees (such as proceedings conducted by State
professional licensing and disciplinary boards and State
Medicaid Fraud Control Units), and Federal criminal history
records, including a fingerprint check using the Integrated
Automated Fingerprint Identification System of the Federal
Bureau of Investigation;
(B) require States to describe and test methods that reduce
duplicative fingerprinting, including providing for the
development of ``rap back'' capability by the State such
that, if a direct patient access employee of a long-term care
facility or provider is convicted of a crime following the
initial criminal history background check conducted with
respect to such employee, and the employee's fingerprints
match the prints on file with the State law enforcement
department, the department will immediately inform the State
and the State will immediately inform the long-term care
facility or provider which employs the direct patient access
employee of such conviction; and
(C) require that criminal history background checks
conducted under the nationwide program remain valid for a
period of time specified by the Secretary.
(4) State requirements.--An agreement entered into under
paragraph (1) shall require that a participating State--
(A) be responsible for monitoring compliance with the
requirements of the nationwide program;
(B) have procedures in place to--
(i) conduct screening and criminal history background
checks under the nationwide program in accordance with the
requirements of this section;
(ii) monitor compliance by long-term care facilities and
providers with the procedures and requirements of the
nationwide program;
(iii) as appropriate, provide for a provisional period of
employment by a long-term care facility or provider of a
direct patient access employee, not to exceed 60 days,
pending completion of the required criminal history
background check and, in the case where the employee has
appealed the results of such background check, pending
completion of the appeals process, during which the employee
shall be subject to direct on-site supervision (in accordance
with procedures established by the State to ensure that a
long-term care facility or provider furnishes such direct on-
site supervision);
(iv) provide an independent process by which a provisional
employee or an employee may appeal or dispute the accuracy of
the information obtained in a background check performed
under the nationwide program, including the specification of
criteria for appeals for direct patient access employees
found to have disqualifying information which shall include
consideration of the passage of time, extenuating
circumstances, demonstration of rehabilitation, and relevancy
of the particular disqualifying information with respect to
the current employment of the individual;
(v) provide for the designation of a single State agency as
responsible for--
(I) overseeing the coordination of any State and national
criminal history background checks requested by a long-term
care facility or provider (or the designated agent of the
long-term care facility or provider) utilizing a search of
State and Federal criminal history records, including a
fingerprint check of such records;
(II) overseeing the design of appropriate privacy and
security safeguards for use in the review of the results of
any State or national criminal history background checks
conducted regarding a prospective direct patient access
employee to determine whether the employee has any conviction
for a relevant crime;
(III) immediately reporting to the long-term care facility
or provider that requested the criminal history background
check the results of such review; and
[[Page H2076]]
(IV) in the case of an employee with a conviction for a
relevant crime that is subject to reporting under section
1128E of the Social Security Act (42 U.S.C. 1320a-7e),
reporting the existence of such conviction to the database
established under that section;
(vi) determine which individuals are direct patient access
employees (as defined in paragraph (6)(B)) for purposes of
the nationwide program;
(vii) as appropriate, specify offenses, including
convictions for violent crimes, for purposes of the
nationwide program; and
(viii) describe and test methods that reduce duplicative
fingerprinting, including providing for the development of
``rap back'' capability such that, if a direct patient access
employee of a long-term care facility or provider is
convicted of a crime following the initial criminal history
background check conducted with respect to such employee, and
the employee's fingerprints match the prints on file with the
State law enforcement department--
(I) the department will immediately inform the State agency
designated under clause (v) and such agency will immediately
inform the facility or provider which employs the direct
patient access employee of such conviction; and
(II) the State will provide, or will require the facility
to provide, to the employee a copy of the results of the
criminal history background check conducted with respect to
the employee at no charge in the case where the individual
requests such a copy.
(5) Payments.--
(A) Newly participating states.--
(i) In general.--As part of the application submitted by a
State under paragraph (1)(A)(iii), the State shall guarantee,
with respect to the costs to be incurred by the State in
carrying out the nationwide program, that the State will make
available (directly or through donations from public or
private entities) a particular amount of non-Federal
contributions, as a condition of receiving the Federal match
under clause (ii).
(ii) Federal match.--The payment amount to each State that
the Secretary enters into an agreement with under paragraph
(1)(A) shall be 3 times the amount that the State guarantees
to make available under clause (i), except that in no case
may the payment amount exceed $3,000,000.
(B) Previously participating states.--
(i) In general.--As part of the application submitted by a
State under paragraph (1)(B)(iii), the State shall guarantee,
with respect to the costs to be incurred by the State in
carrying out the nationwide program, that the State will make
available (directly or through donations from public or
private entities) a particular amount of non-Federal
contributions, as a condition of receiving the Federal match
under clause (ii).
(ii) Federal match.--The payment amount to each State that
the Secretary enters into an agreement with under paragraph
(1)(B) shall be 3 times the amount that the State guarantees
to make available under clause (i), except that in no case
may the payment amount exceed $1,500,000.
(6) Definitions.--Under the nationwide program:
(A) Conviction for a relevant crime.--The term ``conviction
for a relevant crime'' means any Federal or State criminal
conviction for--
(i) any offense described in section 1128(a) of the Social
Security Act (42 U.S.C. 1320a-7); or
(ii) such other types of offenses as a participating State
may specify for purposes of conducting the program in such
State.
(B) Disqualifying information.--The term ``disqualifying
information'' means a conviction for a relevant crime or a
finding of patient or resident abuse.
(C) Finding of patient or resident abuse.--The term
``finding of patient or resident abuse'' means any
substantiated finding by a State agency under section
1819(g)(1)(C) or 1919(g)(1)(C) of the Social Security Act (42
U.S.C. 1395i-3(g)(1)(C), 1396r(g)(1)(C)) or a Federal agency
that a direct patient access employee has committed--
(i) an act of patient or resident abuse or neglect or a
misappropriation of patient or resident property; or
(ii) such other types of acts as a participating State may
specify for purposes of conducting the program in such State.
(D) Direct patient access employee.--The term ``direct
patient access employee'' means any individual who has access
to a patient or resident of a long-term care facility or
provider through employment or through a contract with such
facility or provider and has duties that involve (or may
involve) one-on-one contact with a patient or resident of the
facility or provider, as determined by the State for purposes
of the nationwide program. Such term does not include a
volunteer unless the volunteer has duties that are equivalent
to the duties of a direct patient access employee and those
duties involve (or may involve) one-on-one contact with a
patient or resident of the long-term care facility or
provider.
(E) Long-term care facility or provider.--The term ``long-
term care facility or provider'' means the following
facilities or providers which receive payment for services
under title XVIII or XIX of the Social Security Act:
(i) A skilled nursing facility (as defined in section
1819(a) of the Social Security Act (42 U.S.C. 1395i-3(a))).
(ii) A nursing facility (as defined in section 1919(a) of
such Act (42 U.S.C. 1396r(a))).
(iii) A home health agency.
(iv) A provider of hospice care (as defined in section
1861(dd)(1) of such Act (42 U.S.C. 1395x(dd)(1))).
(v) A long-term care hospital (as described in section
1886(d)(1)(B)(iv) of such Act (42 U.S.C.
1395ww(d)(1)(B)(iv))).
(vi) A provider of personal care services.
(vii) A provider of adult day care.
(viii) A residential care provider that arranges for, or
directly provides, long-term care services, including an
assisted living facility that provides a level of care
established by the Secretary.
(ix) An intermediate care facility for the mentally
retarded (as defined in section 1905(d) of such Act (42
U.S.C. 1396d(d))).
(x) Any other facility or provider of long-term care
services under such titles as the participating State
determines appropriate.
(7) Evaluation and report.--
(A) Evaluation.--
(i) In general.--The Inspector General of the Department of
Health and Human Services shall conduct an evaluation of the
nationwide program.
(ii) Inclusion of specific topics.--The evaluation
conducted under clause (i) shall include the following:
(I) A review of the various procedures implemented by
participating States for long-term care facilities or
providers, including staffing agencies, to conduct background
checks of direct patient access employees under the
nationwide program and identification of the most
appropriate, efficient, and effective procedures for
conducting such background checks.
(II) An assessment of the costs of conducting such
background checks (including start up and administrative
costs).
(III) A determination of the extent to which conducting
such background checks leads to any unintended consequences,
including a reduction in the available workforce for long-
term care facilities or providers.
(IV) An assessment of the impact of the nationwide program
on reducing the number of incidents of neglect, abuse, and
misappropriation of resident property to the extent
practicable.
(V) An evaluation of other aspects of the nationwide
program, as determined appropriate by the Secretary.
(B) Report.--Not later than 180 days after the completion
of the nationwide program, the Inspector General of the
Department of Health and Human Services shall submit a report
to Congress containing the results of the evaluation
conducted under subparagraph (A).
(b) Funding.--
(1) Notification.--The Secretary of Health and Human
Services shall notify the Secretary of the Treasury of the
amount necessary to carry out the nationwide program under
this section for the period of fiscal years 2010 through
2012, except that in no case shall such amount exceed
$160,000,000.
(2) Transfer of funds.--
(A) In general.--Out of any funds in the Treasury not
otherwise appropriated, the Secretary of the Treasury shall
provide for the transfer to the Secretary of Health and Human
Services of the amount specified as necessary to carry out
the nationwide program under paragraph (1). Such amount shall
remain available until expended.
(B) Reservation of funds for conduct of evaluation.--The
Secretary may reserve not more than $3,000,000 of the amount
transferred under subparagraph (A) to provide for the conduct
of the evaluation under subsection (a)(7)(A).
Subtitle D--Patient-Centered Outcomes Research
SEC. 6301. PATIENT-CENTERED OUTCOMES RESEARCH.
(a) In General.--Title XI of the Social Security Act (42
U.S.C. 1301 et seq.) is amended by adding at the end the
following new part:
``Part D--Comparative Clinical Effectiveness Research
``comparative clinical effectiveness research
``Sec. 1181. (a) Definitions.--In this section:
``(1) Board.--The term `Board' means the Board of Governors
established under subsection (f).
``(2) Comparative clinical effectiveness research;
research.--
``(A) In general.--The terms `comparative clinical
effectiveness research' and `research' mean research
evaluating and comparing health outcomes and the clinical
effectiveness, risks, and benefits of 2 or more medical
treatments, services, and items described in subparagraph
(B).
``(B) Medical treatments, services, and items described.--
The medical treatments, services, and items described in this
subparagraph are health care interventions, protocols for
treatment, care management, and delivery, procedures, medical
devices, diagnostic tools, pharmaceuticals (including drugs
and biologicals), integrative health practices, and any other
strategies or items being used in the treatment, management,
and diagnosis of, or prevention of illness or injury in,
individuals.
``(3) Conflict of interest.--The term `conflict of
interest' means an association, including a financial or
personal association, that have the potential to bias or have
the appearance of biasing an individual's decisions in
matters related to the Institute or the conduct of activities
under this section.
``(4) Real conflict of interest.--The term `real conflict
of interest' means any instance where a member of the Board,
the methodology committee established under subsection
(d)(6), or an advisory panel appointed under subsection
(d)(4), or a close relative of such member, has received or
could receive either of the following:
``(A) A direct financial benefit of any amount deriving
from the result or findings of a study conducted under this
section.
``(B) A financial benefit from individuals or companies
that own or manufacture medical treatments, services, or
items to be studied under this section that in the aggregate
exceeds $10,000 per year. For purposes of the preceding
sentence, a financial benefit includes honoraria,
[[Page H2077]]
fees, stock, or other financial benefit and the current value
of the member or close relative's already existing stock
holdings, in addition to any direct financial benefit
deriving from the results or findings of a study conducted
under this section.
``(b) Patient-Centered Outcomes Research Institute.--
``(1) Establishment.--There is authorized to be established
a nonprofit corporation, to be known as the `Patient-Centered
Outcomes Research Institute' (referred to in this section as
the `Institute') which is neither an agency nor establishment
of the United States Government.
``(2) Application of provisions.--The Institute shall be
subject to the provisions of this section, and, to the extent
consistent with this section, to the District of Columbia
Nonprofit Corporation Act.
``(3) Funding of comparative clinical effectiveness
research.--For fiscal year 2010 and each subsequent fiscal
year, amounts in the Patient-Centered Outcomes Research Trust
Fund (referred to in this section as the `PCORTF') under
section 9511 of the Internal Revenue Code of 1986 shall be
available, without further appropriation, to the Institute to
carry out this section.
``(c) Purpose.--The purpose of the Institute is to assist
patients, clinicians, purchasers, and policy-makers in making
informed health decisions by advancing the quality and
relevance of evidence concerning the manner in which
diseases, disorders, and other health conditions can
effectively and appropriately be prevented, diagnosed,
treated, monitored, and managed through research and evidence
synthesis that considers variations in patient
subpopulations, and the dissemination of research findings
with respect to the relative health outcomes, clinical
effectiveness, and appropriateness of the medical treatments,
services, and items described in subsection (a)(2)(B).
``(d) Duties.--
``(1) Identifying research priorities and establishing
research project agenda.--
``(A) Identifying research priorities.--The Institute shall
identify national priorities for research, taking into
account factors of disease incidence, prevalence, and burden
in the United States (with emphasis on chronic conditions),
gaps in evidence in terms of clinical outcomes, practice
variations and health disparities in terms of delivery and
outcomes of care, the potential for new evidence to improve
patient health, well-being, and the quality of care, the
effect on national expenditures associated with a health care
treatment, strategy, or health conditions, as well as patient
needs, outcomes, and preferences, the relevance to patients
and clinicians in making informed health decisions, and
priorities in the National Strategy for quality care
established under section 399H of the Public Health Service
Act that are consistent with this section.
``(B) Establishing research project agenda.--The Institute
shall establish and update a research project agenda for
research to address the priorities identified under
subparagraph (A), taking into consideration the types of
research that might address each priority and the relative
value (determined based on the cost of conducting research
compared to the potential usefulness of the information
produced by research) associated with the different types of
research, and such other factors as the Institute determines
appropriate.
``(2) Carrying out research project agenda.--
``(A) Research.--The Institute shall carry out the research
project agenda established under paragraph (1)(B) in
accordance with the methodological standards adopted under
paragraph (9) using methods, including the following:
``(i) Systematic reviews and assessments of existing and
future research and evidence including original research
conducted subsequent to the date of the enactment of this
section.
``(ii) Primary research, such as randomized clinical
trials, molecularly informed trials, and observational
studies.
``(iii) Any other methodologies recommended by the
methodology committee established under paragraph (6) that
are adopted by the Board under paragraph (9).
``(B) Contracts for the management of funding and conduct
of research.--
``(i) Contracts.--
``(I) In general.--In accordance with the research project
agenda established under paragraph (1)(B), the Institute
shall enter into contracts for the management of funding and
conduct of research in accordance with the following:
``(aa) Appropriate agencies and instrumentalities of the
Federal Government.
``(bb) Appropriate academic research, private sector
research, or study-conducting entities.
``(II) Preference.--In entering into contracts under
subclause (I), the Institute shall give preference to the
Agency for Healthcare Research and Quality and the National
Institutes of Health, but only if the research to be
conducted or managed under such contract is authorized by the
governing statutes of such Agency or Institutes.
``(ii) Conditions for contracts.--A contract entered into
under this subparagraph shall require that the agency,
instrumentality, or other entity--
``(I) abide by the transparency and conflicts of interest
requirements under subsection (h) that apply to the Institute
with respect to the research managed or conducted under such
contract;
``(II) comply with the methodological standards adopted
under paragraph (9) with respect to such research;
``(III) consult with the expert advisory panels for
clinical trials and rare disease appointed under clauses (ii)
and (iii), respectively, of paragraph (4)(A);
``(IV) subject to clause (iv), permit a researcher who
conducts original research under the contract for the agency,
instrumentality, or other entity to have such research
published in a peer-reviewed journal or other publication;
``(V) have appropriate processes in place to manage data
privacy and meet ethical standards for the research;
``(VI) comply with the requirements of the Institute for
making the information available to the public under
paragraph (8); and
``(VII) comply with other terms and conditions determined
necessary by the Institute to carry out the research agenda
adopted under paragraph (2).
``(iii) Coverage of copayments or coinsurance.--A contract
entered into under this subparagraph may allow for the
coverage of copayments or coinsurance, or allow for other
appropriate measures, to the extent that such coverage or
other measures are necessary to preserve the validity of a
research project, such as in the case where the research
project must be blinded.
``(iv) Requirements for publication of research.--Any
research published under clause (ii)(IV) shall be within the
bounds of and entirely consistent with the evidence and
findings produced under the contract with the Institute under
this subparagraph. If the Institute determines that those
requirements are not met, the Institute shall not enter into
another contract with the agency, instrumentality, or entity
which managed or conducted such research for a period
determined appropriate by the Institute (but not less than 5
years).
``(C) Review and update of evidence.--The Institute shall
review and update evidence on a periodic basis as
appropriate.
``(D) Taking into account potential differences.--Research
shall be designed, as appropriate, to take into account the
potential for differences in the effectiveness of health care
treatments, services, and items as used with various
subpopulations, such as racial and ethnic minorities, women,
age, and groups of individuals with different comorbidities,
genetic and molecular sub-types, or quality of life
preferences and include members of such subpopulations as
subjects in the research as feasible and appropriate.
``(E) Differences in treatment modalities.--Research shall
be designed, as appropriate, to take into account different
characteristics of treatment modalities that may affect
research outcomes, such as the phase of the treatment
modality in the innovation cycle and the impact of the skill
of the operator of the treatment modality.
``(3) Data collection.--
``(A) In general.--The Secretary shall, with appropriate
safeguards for privacy, make available to the Institute such
data collected by the Centers for Medicare & Medicaid
Services under the programs under titles XVIII, XIX, and XXI,
as well as provide access to the data networks developed
under section 937(f) of the Public Health Service Act, as the
Institute and its contractors may require to carry out this
section. The Institute may also request and obtain data from
Federal, State, or private entities, including data from
clinical databases and registries.
``(B) Use of data.--The Institute shall only use data
provided to the Institute under subparagraph (A) in
accordance with laws and regulations governing the release
and use of such data, including applicable confidentiality
and privacy standards.
``(4) Appointing expert advisory panels.--
``(A) Appointment.--
``(i) In general.--The Institute may appoint permanent or
ad hoc expert advisory panels as determined appropriate to
assist in identifying research priorities and establishing
the research project agenda under paragraph (1) and for other
purposes.
``(ii) Expert advisory panels for clinical trials.--The
Institute shall appoint expert advisory panels in carrying
out randomized clinical trials under the research project
agenda under paragraph (2)(A)(ii). Such expert advisory
panels shall advise the Institute and the agency,
instrumentality, or entity conducting the research on the
research question involved and the research design or
protocol, including important patient subgroups and other
parameters of the research. Such panels shall be available as
a resource for technical questions that may arise during the
conduct of such research.
``(iii) Expert advisory panel for rare disease.--In the
case of a research study for rare disease, the Institute
shall appoint an expert advisory panel for purposes of
assisting in the design of the research study and determining
the relative value and feasibility of conducting the research
study.
``(B) Composition.--An expert advisory panel appointed
under subparagraph (A) shall include representatives of
practicing and research clinicians, patients, and experts in
scientific and health services research, health services
delivery, and evidence-based medicine who have experience in
the relevant topic, and as appropriate, experts in
integrative health and primary prevention strategies. The
Institute may include a technical expert of each manufacturer
or each medical technology that is included under the
relevant topic, project, or category for which the panel is
established.
``(5) Supporting patient and consumer representatives.--The
Institute shall provide support and resources to help patient
and consumer representatives effectively participate on the
Board and expert advisory panels appointed by the Institute
under paragraph (4).
``(6) Establishing methodology committee.--
``(A) In general.--The Institute shall establish a standing
methodology committee to carry out the functions described in
subparagraph (C).
[[Page H2078]]
``(B) Appointment and composition.--The methodology
committee established under subparagraph (A) shall be
composed of not more than 15 members appointed by the
Comptroller General of the United States. Members appointed
to the methodology committee shall be experts in their
scientific field, such as health services research, clinical
research, comparative clinical effectiveness research,
biostatistics, genomics, and research methodologies.
Stakeholders with such expertise may be appointed to the
methodology committee. In addition to the members appointed
under the first sentence, the Directors of the National
Institutes of Health and the Agency for Healthcare Research
and Quality (or their designees) shall each be included as
members of the methodology committee.
``(C) Functions.--Subject to subparagraph (D), the
methodology committee shall work to develop and improve the
science and methods of comparative clinical effectiveness
research by, not later than 18 months after the establishment
of the Institute, directly or through subcontract, developing
and periodically updating the following:
``(i) Methodological standards for research. Such
methodological standards shall provide specific criteria for
internal validity, generalizability, feasibility, and
timeliness of research and for health outcomes measures, risk
adjustment, and other relevant aspects of research and
assessment with respect to the design of research. Any
methodological standards developed and updated under this
subclause shall be scientifically based and include methods
by which new information, data, or advances in technology are
considered and incorporated into ongoing research projects by
the Institute, as appropriate. The process for developing and
updating such standards shall include input from relevant
experts, stakeholders, and decisionmakers, and shall provide
opportunities for public comment. Such standards shall also
include methods by which patient subpopulations can be
accounted for and evaluated in different types of research.
As appropriate, such standards shall build on existing work
on methodological standards for defined categories of health
interventions and for each of the major categories of
comparative clinical effectiveness research methods
(determined as of the date of enactment of the Patient
Protection and Affordable Care Act).
``(ii) A translation table that is designed to provide
guidance and act as a reference for the Board to determine
research methods that are most likely to address each
specific research question.
``(D) Consultation and conduct of examinations.--The
methodology committee may consult and contract with the
Institute of Medicine of the National Academies and academic,
nonprofit, or other private and governmental entities with
relevant expertise to carry out activities described in
subparagraph (C) and may consult with relevant stakeholders
to carry out such activities.
``(E) Reports.--The methodology committee shall submit
reports to the Board on the committee's performance of the
functions described in subparagraph (C). Reports shall
contain recommendations for the Institute to adopt
methodological standards developed and updated by the
methodology committee as well as other actions deemed
necessary to comply with such methodological standards.
``(7) Providing for a peer-review process for primary
research.--
``(A) In general.--The Institute shall ensure that there is
a process for peer review of primary research described in
subparagraph (A)(ii) of paragraph (2) that is conducted under
such paragraph. Under such process--
``(i) evidence from such primary research shall be reviewed
to assess scientific integrity and adherence to
methodological standards adopted under paragraph (9); and
``(ii) a list of the names of individuals contributing to
any peer-review process during the preceding year or years
shall be made public and included in annual reports in
accordance with paragraph (10)(D).
``(B) Composition.--Such peer-review process shall be
designed in a manner so as to avoid bias and conflicts of
interest on the part of the reviewers and shall be composed
of experts in the scientific field relevant to the research
under review.
``(C) Use of existing processes.--
``(i) Processes of another entity.--In the case where the
Institute enters into a contract or other agreement with
another entity for the conduct or management of research
under this section, the Institute may utilize the peer-review
process of such entity if such process meets the requirements
under subparagraphs (A) and (B).
``(ii) Processes of appropriate medical journals.--The
Institute may utilize the peer-review process of appropriate
medical journals if such process meets the requirements under
subparagraphs (A) and (B).
``(8) Release of research findings.--
``(A) In general.--The Institute shall, not later than 90
days after the conduct or receipt of research findings under
this part, make such research findings available to
clinicians, patients, and the general public. The Institute
shall ensure that the research findings--
``(i) convey the findings of research in a manner that is
comprehensible and useful to patients and providers in making
health care decisions;
``(ii) fully convey findings and discuss considerations
specific to certain subpopulations, risk factors, and
comorbidities, as appropriate;
``(iii) include limitations of the research and what
further research may be needed as appropriate;
``(iv) not be construed as mandates for practice
guidelines, coverage recommendations, payment, or policy
recommendations; and
``(v) not include any data which would violate the privacy
of research participants or any confidentiality agreements
made with respect to the use of data under this section.
``(B) Definition of research findings.--In this paragraph,
the term `research findings' means the results of a study or
assessment.
``(9) Adoption.--Subject to subsection (h)(1), the
Institute shall adopt the national priorities identified
under paragraph (1)(A), the research project agenda
established under paragraph (1)(B), the methodological
standards developed and updated by the methodology committee
under paragraph (6)(C)(i), and any peer-review process
provided under paragraph (7) by majority vote. In the case
where the Institute does not adopt such processes in
accordance with the preceding sentence, the processes shall
be referred to the appropriate staff or entity within the
Institute (or, in the case of the methodological standards,
the methodology committee) for further review.
``(10) Annual reports.--The Institute shall submit an
annual report to Congress and the President, and shall make
the annual report available to the public. Such report shall
contain--
``(A) a description of the activities conducted under this
section, research priorities identified under paragraph
(1)(A) and methodological standards developed and updated by
the methodology committee under paragraph (6)(C)(i) that are
adopted under paragraph (9) during the preceding year;
``(B) the research project agenda and budget of the
Institute for the following year;
``(C) any administrative activities conducted by the
Institute during the preceding year;
``(D) the names of individuals contributing to any peer-
review process under paragraph (7), without identifying them
with a particular research project; and
``(E) any other relevant information (including information
on the membership of the Board, expert advisory panels,
methodology committee, and the executive staff of the
Institute, any conflicts of interest with respect to these
individuals, and any bylaws adopted by the Board during the
preceding year).
``(e) Administration.--
``(1) In general.--Subject to paragraph (2), the Board
shall carry out the duties of the Institute.
``(2) Nondelegable duties.--The activities described in
subsections (d)(1) and (d)(9) are nondelegable.
``(f) Board of Governors.--
``(1) In general.--The Institute shall have a Board of
Governors, which shall consist of the following members:
``(A) The Director of Agency for Healthcare Research and
Quality (or the Director's designee).
``(B) The Director of the National Institutes of Health (or
the Director's designee).
``(C) Seventeen members appointed, not later than 6 months
after the date of enactment of this section, by the
Comptroller General of the United States as follows:
``(i) 3 members representing patients and health care
consumers.
``(ii) 5 members representing physicians and providers,
including at least 1 surgeon, nurse, State-licensed
integrative health care practitioner, and representative of a
hospital.
``(iii) 3 members representing private payers, of whom at
least 1 member shall represent health insurance issuers and
at least 1 member shall represent employers who self-insure
employee benefits.
``(iv) 3 members representing pharmaceutical, device, and
diagnostic manufacturers or developers.
``(v) 1 member representing quality improvement or
independent health service researchers.
``(vi) 2 members representing the Federal Government or the
States, including at least 1 member representing a Federal
health program or agency.
``(2) Qualifications.--The Board shall represent a broad
range of perspectives and collectively have scientific
expertise in clinical health sciences research, including
epidemiology, decisions sciences, health economics, and
statistics. In appointing the Board, the Comptroller General
of the United States shall consider and disclose any
conflicts of interest in accordance with subsection
(h)(4)(B). Members of the Board shall be recused from
relevant Institute activities in the case where the member
(or an immediate family member of such member) has a real
conflict of interest directly related to the research project
or the matter that could affect or be affected by such
participation.
``(3) Terms; vacancies.--A member of the Board shall be
appointed for a term of 6 years, except with respect to the
members first appointed, whose terms of appointment shall be
staggered evenly over 2-year increments. No individual shall
be appointed to the Board for more than 2 terms. Vacancies
shall be filled in the same manner as the original
appointment was made.
``(4) Chairperson and vice-chairperson.--The Comptroller
General of the United States shall designate a Chairperson
and Vice Chairperson of the Board from among the members of
the Board. Such members shall serve as Chairperson or Vice
Chairperson for a period of 3 years.
``(5) Compensation.--Each member of the Board who is not an
officer or employee of the Federal Government shall be
entitled to compensation (equivalent to the rate provided for
level IV of the Executive Schedule under section 5315 of
title 5, United States Code) and expenses incurred while
performing the duties of the Board. An officer or employee of
the Federal government who is a member of the Board shall be
exempt from compensation.
``(6) Director and staff; experts and consultants.--The
Board may employ and fix the
[[Page H2079]]
compensation of an Executive Director and such other
personnel as may be necessary to carry out the duties of the
Institute and may seek such assistance and support of, or
contract with, experts and consultants that may be necessary
for the performance of the duties of the Institute.
``(7) Meetings and hearings.--The Board shall meet and hold
hearings at the call of the Chairperson or a majority of its
members. Meetings not solely concerning matters of personnel
shall be advertised at least 7 days in advance and open to
the public. A majority of the Board members shall constitute
a quorum, but a lesser number of members may meet and hold
hearings.
``(g) Financial and Governmental Oversight.--
``(1) Contract for audit.--The Institute shall provide for
the conduct of financial audits of the Institute on an annual
basis by a private entity with expertise in conducting
financial audits.
``(2) Review and annual reports.--
``(A) Review.--The Comptroller General of the United States
shall review the following:
``(i) Not less frequently than on an annual basis, the
financial audits conducted under paragraph (1).
``(ii) Not less frequently than every 5 years, the
processes established by the Institute, including the
research priorities and the conduct of research projects, in
order to determine whether information produced by such
research projects is objective and credible, is produced in a
manner consistent with the requirements under this section,
and is developed through a transparent process.
``(iii) Not less frequently than every 5 years, the
dissemination and training activities and data networks
established under section 937 of the Public Health Service
Act, including the methods and products used to disseminate
research, the types of training conducted and supported, and
the types and functions of the data networks established, in
order to determine whether the activities and data are
produced in a manner consistent with the requirements under
such section.
``(iv) Not less frequently than every 5 years, the overall
effectiveness of activities conducted under this section and
the dissemination, training, and capacity building activities
conducted under section 937 of the Public Health Service Act.
Such review shall include an analysis of the extent to which
research findings are used by health care decision-makers,
the effect of the dissemination of such findings on reducing
practice variation and disparities in health care, and the
effect of the research conducted and disseminated on
innovation and the health care economy of the United States.
``(v) Not later than 8 years after the date of enactment of
this section, the adequacy and use of the funding for the
Institute and the activities conducted under section 937 of
the Public Health Service Act, including a determination as
to whether, based on the utilization of research findings by
public and private payers, funding sources for the Patient-
Centered Outcomes Research Trust Fund under section 9511 of
the Internal Revenue Code of 1986 are appropriate and whether
such sources of funding should be continued or adjusted.
``(B) Annual reports.--Not later than April 1 of each year,
the Comptroller General of the United States shall submit to
Congress a report containing the results of the review
conducted under subparagraph (A) with respect to the
preceding year (or years, if applicable), together with
recommendations for such legislation and administrative
action as the Comptroller General determines appropriate.
``(h) Ensuring Transparency, Credibility, and Access.--The
Institute shall establish procedures to ensure that the
following requirements for ensuring transparency,
credibility, and access are met:
``(1) Public comment periods.--The Institute shall provide
for a public comment period of not less than 45 days and not
more than 60 days prior to the adoption under subsection
(d)(9) of the national priorities identified under subsection
(d)(1)(A), the research project agenda established under
subsection (d)(1)(B), the methodological standards developed
and updated by the methodology committee under subsection
(d)(6)(C)(i), and the peer-review process provided under
paragraph (7), and after the release of draft findings with
respect to systematic reviews of existing research and
evidence.
``(2) Additional forums.--The Institute shall support
forums to increase public awareness and obtain and
incorporate public input and feedback through media (such as
an Internet website) on research priorities, research
findings, and other duties, activities, or processes the
Institute determines appropriate.
``(3) Public availability.--The Institute shall make
available to the public and disclose through the official
public Internet website of the Institute the following:
``(A) Information contained in research findings as
specified in subsection (d)(9).
``(B) The process and methods for the conduct of research,
including the identity of the entity and the investigators
conducing such research and any conflicts of interests of
such parties, any direct or indirect links the entity has to
industry, and research protocols, including measures taken,
methods of research and analysis, research results, and such
other information the Institute determines appropriate)
concurrent with the release of research findings.
``(C) Notice of public comment periods under paragraph (1),
including deadlines for public comments.
``(D) Subsequent comments received during each of the
public comment periods.
``(E) In accordance with applicable laws and processes and
as the Institute determines appropriate, proceedings of the
Institute.
``(4) Disclosure of conflicts of interest.--
``(A) In general.--A conflict of interest shall be
disclosed in the following manner:
``(i) By the Institute in appointing members to an expert
advisory panel under subsection (d)(4), in selecting
individuals to contribute to any peer-review process under
subsection (d)(7), and for employment as executive staff of
the Institute.
``(ii) By the Comptroller General in appointing members of
the methodology committee under subsection (d)(6);
``(iii) By the Institute in the annual report under
subsection (d)(10), except that, in the case of individuals
contributing to any such peer review process, such
description shall be in a manner such that those individuals
cannot be identified with a particular research project.
``(B) Manner of disclosure.--Conflicts of interest shall be
disclosed as described in subparagraph (A) as soon as
practicable on the Internet web site of the Institute and of
the Government Accountability Office. The information
disclosed under the preceding sentence shall include the
type, nature, and magnitude of the interests of the
individual involved, except to the extent that the individual
recuses himself or herself from participating in the
consideration of or any other activity with respect to the
study as to which the potential conflict exists.
``(i) Rules.--The Institute, its Board or staff, shall be
prohibited from accepting gifts, bequeaths, or donations of
services or property. In addition, the Institute shall be
prohibited from establishing a corporation or generating
revenues from activities other than as provided under this
section.
``(j) Rules of Construction.--
``(1) Coverage.--Nothing in this section shall be
construed--
``(A) to permit the Institute to mandate coverage,
reimbursement, or other policies for any public or private
payer; or
``(B) as preventing the Secretary from covering the routine
costs of clinical care received by an individual entitled to,
or enrolled for, benefits under title XVIII, XIX, or XXI in
the case where such individual is participating in a clinical
trial and such costs would otherwise be covered under such
title with respect to the beneficiary.''.
(b) Dissemination and Building Capacity for Research.--
Title IX of the Public Health Service Act (42 U.S.C. 299 et
seq.), as amended by section 3606, is further amended by
inserting after section 936 the following:
``SEC. 937. DISSEMINATION AND BUILDING CAPACITY FOR RESEARCH.
``(a) In General.--
``(1) Dissemination.--The Office of Communication and
Knowledge Transfer (referred to in this section as the
`Office') at the Agency for Healthcare Research and Quality
(or any other relevant office designated by Agency for
Healthcare Research and Quality), in consultation with the
National Institutes of Health, shall broadly disseminate the
research findings that are published by the Patient Centered
Outcomes Research Institute established under section 1181(b)
of the Social Security Act (referred to in this section as
the `Institute') and other government-funded research
relevant to comparative clinical effectiveness research. The
Office shall create informational tools that organize and
disseminate research findings for physicians, health care
providers, patients, payers, and policy makers. The Office
shall also develop a publicly available resource database
that collects and contains government-funded evidence and
research from public, private, not-for profit, and academic
sources.
``(2) Requirements.--The Office shall provide for the
dissemination of the Institute's research findings and
government-funded research relevant to comparative clinical
effectiveness research to physicians, health care providers,
patients, vendors of health information technology focused on
clinical decision support, appropriate professional
associations, and Federal and private health plans.
Materials, forums, and media used to disseminate the
findings, informational tools, and resource databases shall--
``(A) include a description of considerations for specific
subpopulations, the research methodology, and the limitations
of the research, and the names of the entities, agencies,
instrumentalities, and individuals who conducted any research
which was published by the Institute; and
``(B) not be construed as mandates, guidelines, or
recommendations for payment, coverage, or treatment.
``(b) Incorporation of Research Findings.--The Office, in
consultation with relevant medical and clinical associations,
shall assist users of health information technology focused
on clinical decision support to promote the timely
incorporation of research findings disseminated under
subsection (a) into clinical practices and to promote the
ease of use of such incorporation.
``(c) Feedback.--The Office shall establish a process to
receive feedback from physicians, health care providers,
patients, and vendors of health information technology
focused on clinical decision support, appropriate
professional associations, and Federal and private health
plans about the value of the information disseminated and the
assistance provided under this section.
``(d) Rule of Construction.--Nothing in this section shall
preclude the Institute from making its research findings
publicly available as required under section 1181(d)(8) of
the Social Security Act.
``(e) Training of Researchers.--The Agency for Health Care
Research and Quality, in consultation with the National
Institutes of Health, shall build capacity for comparative
clinical effectiveness research by establishing a grant
program that provides for the training of researchers in the
methods used to conduct such research, including systematic
reviews of existing research and primary research such as
clinical
[[Page H2080]]
trials. At a minimum, such training shall be in methods that
meet the methodological standards adopted under section
1181(d)(9) of the Social Security Act.
``(f) Building Data for Research.--The Secretary shall
provide for the coordination of relevant Federal health
programs to build data capacity for comparative clinical
effectiveness research, including the development and use of
clinical registries and health outcomes research data
networks, in order to develop and maintain a comprehensive,
interoperable data network to collect, link, and analyze data
on outcomes and effectiveness from multiple sources,
including electronic health records.
``(g) Authority To Contract With the Institute.--Agencies
and instrumentalities of the Federal Government may enter
into agreements with the Institute, and accept and retain
funds, for the conduct and support of research described in
this part, provided that the research to be conducted or
supported under such agreements is authorized under the
governing statutes of such agencies and instrumentalities.''.
(c) In General.--Part D of title XI of the Social Security
Act, as added by subsection (a), is amended by adding at the
end the following new section:
``limitations on certain uses of comparative clinical effectiveness
research
``Sec. 1182. (a) The Secretary may only use evidence and
findings from research conducted under section 1181 to make a
determination regarding coverage under title XVIII if such
use is through an iterative and transparent process which
includes public comment and considers the effect on
subpopulations.
``(b) Nothing in section 1181 shall be construed as--
``(1) superceding or modifying the coverage of items or
services under title XVIII that the Secretary determines are
reasonable and necessary under section 1862(l)(1); or
``(2) authorizing the Secretary to deny coverage of items
or services under such title solely on the basis of
comparative clinical effectiveness research.
``(c)(1) The Secretary shall not use evidence or findings
from comparative clinical effectiveness research conducted
under section 1181 in determining coverage, reimbursement, or
incentive programs under title XVIII in a manner that treats
extending the life of an elderly, disabled, or terminally ill
individual as of lower value than extending the life of an
individual who is younger, nondisabled, or not terminally
ill.
``(2) Paragraph (1) shall not be construed as preventing
the Secretary from using evidence or findings from such
comparative clinical effectiveness research in determining
coverage, reimbursement, or incentive programs under title
XVIII based upon a comparison of the difference in the
effectiveness of alternative treatments in extending an
individual's life due to the individual's age, disability, or
terminal illness.
``(d)(1) The Secretary shall not use evidence or findings
from comparative clinical effectiveness research conducted
under section 1181 in determining coverage, reimbursement, or
incentive programs under title XVIII in a manner that
precludes, or with the intent to discourage, an individual
from choosing a health care treatment based on how the
individual values the tradeoff between extending the length
of their life and the risk of disability.
``(2)(A) Paragraph (1) shall not be construed to--
``(i) limit the application of differential copayments
under title XVIII based on factors such as cost or type of
service; or
``(ii) prevent the Secretary from using evidence or
findings from such comparative clinical effectiveness
research in determining coverage, reimbursement, or incentive
programs under such title based upon a comparison of the
difference in the effectiveness of alternative health care
treatments in extending an individual's life due to that
individual's age, disability, or terminal illness.
``(3) Nothing in the provisions of, or amendments made by
the Patient Protection and Affordable Care Act, shall be
construed to limit comparative clinical effectiveness
research or any other research, evaluation, or dissemination
of information concerning the likelihood that a health care
treatment will result in disability.
``(e) The Patient-Centered Outcomes Research Institute
established under section 1181(b)(1) shall not develop or
employ a dollars-per-quality adjusted life year (or similar
measure that discounts the value of a life because of an
individual's disability) as a threshold to establish what
type of health care is cost effective or recommended. The
Secretary shall not utilize such an adjusted life year (or
such a similar measure) as a threshold to determine coverage,
reimbursement, or incentive programs under title XVIII.''.
(d) In General.--Part D of title XI of the Social Security
Act, as added by subsection (a) and amended by subsection
(c), is amended by adding at the end the following new
section:
``trust fund transfers to patient-centered outcomes research trust fund
``Sec. 1183. (a) In General.--The Secretary shall provide
for the transfer, from the Federal Hospital Insurance Trust
Fund under section 1817 and the Federal Supplementary Medical
Insurance Trust Fund under section 1841, in proportion (as
estimated by the Secretary) to the total expenditures during
such fiscal year that are made under title XVIII from the
respective trust fund, to the Patient-Centered Outcomes
Research Trust Fund (referred to in this section as the
`PCORTF') under section 9511 of the Internal Revenue Code of
1986, of the following:
``(1) For fiscal year 2013, an amount equal to $1
multiplied by the average number of individuals entitled to
benefits under part A, or enrolled under part B, of title
XVIII during such fiscal year.
``(2) For each of fiscal years 2014, 2015, 2016, 2017,
2018, and 2019, an amount equal to $2 multiplied by the
average number of individuals entitled to benefits under part
A, or enrolled under part B, of title XVIII during such
fiscal year.
``(b) Adjustments for Increases in Health Care Spending.--
In the case of any fiscal year beginning after September 30,
2014, the dollar amount in effect under subsection (a)(2) for
such fiscal year shall be equal to the sum of such dollar
amount for the previous fiscal year (determined after the
application of this subsection), plus an amount equal to the
product of--
``(1) such dollar amount for the previous fiscal year,
multiplied by
``(2) the percentage increase in the projected per capita
amount of National Health Expenditures, as most recently
published by the Secretary before the beginning of the fiscal
year.''.
(e) Patient-Centered Outcomes Research Trust Fund;
Financing for Trust Fund.--
(1) Establishment of trust fund.--
(A) In general.--Subchapter A of chapter 98 of the Internal
Revenue Code of 1986 (relating to establishment of trust
funds) is amended by adding at the end the following new
section:
``SEC. 9511. PATIENT-CENTERED OUTCOMES RESEARCH TRUST FUND.
``(a) Creation of Trust Fund.--There is established in the
Treasury of the United States a trust fund to be known as the
`Patient-Centered Outcomes Research Trust Fund' (hereafter in
this section referred to as the `PCORTF'), consisting of such
amounts as may be appropriated or credited to such Trust Fund
as provided in this section and section 9602(b).
``(b) Transfers to Fund.--
``(1) Appropriation.--There are hereby appropriated to the
Trust Fund the following:
``(A) For fiscal year 2010, $10,000,000.
``(B) For fiscal year 2011, $50,000,000.
``(C) For fiscal year 2012, $150,000,000.
``(D) For fiscal year 2013--
``(i) an amount equivalent to the net revenues received in
the Treasury from the fees imposed under subchapter B of
chapter 34 (relating to fees on health insurance and self-
insured plans) for such fiscal year; and
``(ii) $150,000,000.
``(E) For each of fiscal years 2014, 2015, 2016, 2017,
2018, and 2019--
``(i) an amount equivalent to the net revenues received in
the Treasury from the fees imposed under subchapter B of
chapter 34 (relating to fees on health insurance and self-
insured plans) for such fiscal year; and
``(ii) $150,000,000.
The amounts appropriated under subparagraphs (A), (B), (C),
(D)(ii), and (E)(ii) shall be transferred from the general
fund of the Treasury, from funds not otherwise appropriated.
``(2) Trust fund transfers.--In addition to the amounts
appropriated under paragraph (1), there shall be credited to
the PCORTF the amounts transferred under section 1183 of the
Social Security Act.
``(3) Limitation on transfers to pcortf.--No amount may be
appropriated or transferred to the PCORTF on and after the
date of any expenditure from the PCORTF which is not an
expenditure permitted under this section. The determination
of whether an expenditure is so permitted shall be made
without regard to--
``(A) any provision of law which is not contained or
referenced in this chapter or in a revenue Act, and
``(B) whether such provision of law is a subsequently
enacted provision or directly or indirectly seeks to waive
the application of this paragraph.
``(c) Trustee.--The Secretary of the Treasury shall be a
trustee of the PCORTF.
``(d) Expenditures From Fund.--
``(1) Amounts available to the patient-centered outcomes
research institute.--Subject to paragraph (2), amounts in the
PCORTF are available, without further appropriation, to the
Patient-Centered Outcomes Research Institute established
under section 1181(b) of the Social Security Act for carrying
out part D of title XI of the Social Security Act (as in
effect on the date of enactment of such Act).
``(2) Transfer of funds.--
``(A) In general.--The trustee of the PCORTF shall provide
for the transfer from the PCORTF of 20 percent of the amounts
appropriated or credited to the PCORTF for each of fiscal
years 2011 through 2019 to the Secretary of Health and Human
Services to carry out section 937 of the Public Health
Service Act.
``(B) Availability.--Amounts transferred under subparagraph
(A) shall remain available until expended.
``(C) Requirements.--Of the amounts transferred under
subparagraph (A) with respect to a fiscal year, the Secretary
of Health and Human Services shall distribute--
``(i) 80 percent to the Office of Communication and
Knowledge Transfer of the Agency for Healthcare Research and
Quality (or any other relevant office designated by Agency
for Healthcare Research and Quality) to carry out the
activities described in section 937 of the Public Health
Service Act; and
``(ii) 20 percent to the Secretary to carry out the
activities described in such section 937.
``(e) Net Revenues.--For purposes of this section, the term
`net revenues' means the amount estimated by the Secretary of
the Treasury based on the excess of--
``(1) the fees received in the Treasury under subchapter B
of chapter 34, over
``(2) the decrease in the tax imposed by chapter 1
resulting from the fees imposed by such subchapter.
``(f) Termination.--No amounts shall be available for
expenditure from the PCORTF after September 30, 2019, and any
amounts in such Trust Fund after such date shall be
transferred to the general fund of the Treasury.''.
[[Page H2081]]
(B) Clerical amendment.--The table of sections for
subchapter A of chapter 98 of such Code is amended by adding
at the end the following new item:
``Sec. 9511. Patient-centered outcomes research trust fund.''.
(2) Financing for fund from fees on insured and self-
insured health plans.--
(A) General rule.--Chapter 34 of the Internal Revenue Code
of 1986 is amended by adding at the end the following new
subchapter:
``Subchapter B--Insured and Self-Insured Health Plans
``Sec. 4375. Health insurance.
``Sec. 4376. Self-insured health plans.
``Sec. 4377. Definitions and special rules.
``SEC. 4375. HEALTH INSURANCE.
``(a) Imposition of Fee.--There is hereby imposed on each
specified health insurance policy for each policy year ending
after September 30, 2012, a fee equal to the product of $2
($1 in the case of policy years ending during fiscal year
2013) multiplied by the average number of lives covered under
the policy.
``(b) Liability for Fee.--The fee imposed by subsection (a)
shall be paid by the issuer of the policy.
``(c) Specified Health Insurance Policy.--For purposes of
this section:
``(1) In general.--Except as otherwise provided in this
section, the term `specified health insurance policy' means
any accident or health insurance policy (including a policy
under a group health plan) issued with respect to individuals
residing in the United States.
``(2) Exemption for certain policies.--The term `specified
health insurance policy' does not include any insurance if
substantially all of its coverage is of excepted benefits
described in section 9832(c).
``(3) Treatment of prepaid health coverage arrangements.--
``(A) In general.--In the case of any arrangement described
in subparagraph (B), such arrangement shall be treated as a
specified health insurance policy, and the person referred to
in such subparagraph shall be treated as the issuer.
``(B) Description of arrangements.--An arrangement is
described in this subparagraph if under such arrangement
fixed payments or premiums are received as consideration for
any person's agreement to provide or arrange for the
provision of accident or health coverage to residents of the
United States, regardless of how such coverage is provided or
arranged to be provided.
``(d) Adjustments for Increases in Health Care Spending.--
In the case of any policy year ending in any fiscal year
beginning after September 30, 2014, the dollar amount in
effect under subsection (a) for such policy year shall be
equal to the sum of such dollar amount for policy years
ending in the previous fiscal year (determined after the
application of this subsection), plus an amount equal to the
product of--
``(1) such dollar amount for policy years ending in the
previous fiscal year, multiplied by
``(2) the percentage increase in the projected per capita
amount of National Health Expenditures, as most recently
published by the Secretary before the beginning of the fiscal
year.
``(e) Termination.--This section shall not apply to policy
years ending after September 30, 2019.
``SEC. 4376. SELF-INSURED HEALTH PLANS.
``(a) Imposition of Fee.--In the case of any applicable
self-insured health plan for each plan year ending after
September 30, 2012, there is hereby imposed a fee equal to $2
($1 in the case of plan years ending during fiscal year 2013)
multiplied by the average number of lives covered under the
plan.
``(b) Liability for Fee.--
``(1) In general.--The fee imposed by subsection (a) shall
be paid by the plan sponsor.
``(2) Plan sponsor.--For purposes of paragraph (1) the term
`plan sponsor' means--
``(A) the employer in the case of a plan established or
maintained by a single employer,
``(B) the employee organization in the case of a plan
established or maintained by an employee organization,
``(C) in the case of--
``(i) a plan established or maintained by 2 or more
employers or jointly by 1 or more employers and 1 or more
employee organizations,
``(ii) a multiple employer welfare arrangement, or
``(iii) a voluntary employees' beneficiary association
described in section 501(c)(9), the association, committee,
joint board of trustees, or other similar group of
representatives of the parties who establish or maintain the
plan, or
``(D) the cooperative or association described in
subsection (c)(2)(F) in the case of a plan established or
maintained by such a cooperative or association.
``(c) Applicable Self-insured Health Plan.--For purposes of
this section, the term `applicable self-insured health plan'
means any plan for providing accident or health coverage if--
``(1) any portion of such coverage is provided other than
through an insurance policy, and
``(2) such plan is established or maintained--
``(A) by 1 or more employers for the benefit of their
employees or former employees,
``(B) by 1 or more employee organizations for the benefit
of their members or former members,
``(C) jointly by 1 or more employers and 1 or more employee
organizations for the benefit of employees or former
employees,
``(D) by a voluntary employees' beneficiary association
described in section 501(c)(9),
``(E) by any organization described in section 501(c)(6),
or
``(F) in the case of a plan not described in the preceding
subparagraphs, by a multiple employer welfare arrangement (as
defined in section 3(40) of Employee Retirement Income
Security Act of 1974), a rural electric cooperative (as
defined in section 3(40)(B)(iv) of such Act), or a rural
telephone cooperative association (as defined in section
3(40)(B)(v) of such Act).
``(d) Adjustments for Increases in Health Care Spending.--
In the case of any plan year ending in any fiscal year
beginning after September 30, 2014, the dollar amount in
effect under subsection (a) for such plan year shall be equal
to the sum of such dollar amount for plan years ending in the
previous fiscal year (determined after the application of
this subsection), plus an amount equal to the product of--
``(1) such dollar amount for plan years ending in the
previous fiscal year, multiplied by
``(2) the percentage increase in the projected per capita
amount of National Health Expenditures, as most recently
published by the Secretary before the beginning of the fiscal
year.
``(e) Termination.--This section shall not apply to plan
years ending after September 30, 2019.
``SEC. 4377. DEFINITIONS AND SPECIAL RULES.
``(a) Definitions.--For purposes of this subchapter--
``(1) Accident and health coverage.--The term `accident and
health coverage' means any coverage which, if provided by an
insurance policy, would cause such policy to be a specified
health insurance policy (as defined in section 4375(c)).
``(2) Insurance policy.--The term `insurance policy' means
any policy or other instrument whereby a contract of
insurance is issued, renewed, or extended.
``(3) United states.--The term `United States' includes any
possession of the United States.
``(b) Treatment of Governmental Entities.--
``(1) In general.--For purposes of this subchapter--
``(A) the term `person' includes any governmental entity,
and
``(B) notwithstanding any other law or rule of law,
governmental entities shall not be exempt from the fees
imposed by this subchapter except as provided in paragraph
(2).
``(2) Treatment of exempt governmental programs.--In the
case of an exempt governmental program, no fee shall be
imposed under section 4375 or section 4376 on any covered
life under such program.
``(3) Exempt governmental program defined.--For purposes of
this subchapter, the term `exempt governmental program'
means--
``(A) any insurance program established under title XVIII
of the Social Security Act,
``(B) the medical assistance program established by title
XIX or XXI of the Social Security Act,
``(C) any program established by Federal law for providing
medical care (other than through insurance policies) to
individuals (or the spouses and dependents thereof) by reason
of such individuals being members of the Armed Forces of the
United States or veterans, and
``(D) any program established by Federal law for providing
medical care (other than through insurance policies) to
members of Indian tribes (as defined in section 4(d) of the
Indian Health Care Improvement Act).
``(c) Treatment as Tax.--For purposes of subtitle F, the
fees imposed by this subchapter shall be treated as if they
were taxes.
``(d) No Cover Over to Possessions.--Notwithstanding any
other provision of law, no amount collected under this
subchapter shall be covered over to any possession of the
United States.''.
(B) Clerical amendments.--
(i) Chapter 34 of such Code is amended by striking the
chapter heading and inserting the following:
``CHAPTER 34--TAXES ON CERTAIN INSURANCE POLICIES
``subchapter a. policies issued by foreign insurers
``subchapter b. insured and self-insured health plans
``Subchapter A--Policies Issued By Foreign Insurers''.
(ii) The table of chapters for subtitle D of such Code is
amended by striking the item relating to chapter 34 and
inserting the following new item:
``Chapter 34--Taxes on Certain Insurance Policies''.
(f) Tax-exempt Status of the Patient-centered Outcomes
Research Institute.--Subsection 501(l) of the Internal
Revenue Code of 1986 is amended by adding at the end the
following new paragraph:
``(4) The Patient-Centered Outcomes Research Institute
established under section 1181(b) of the Social Security
Act.''.
SEC. 6302. FEDERAL COORDINATING COUNCIL FOR COMPARATIVE
EFFECTIVENESS RESEARCH.
Notwithstanding any other provision of law, the Federal
Coordinating Council for Comparative Effectiveness Research
established under section 804 of Division A of the American
Recovery and Reinvestment Act of 2009 (42 U.S.C. 299b-8),
including the requirement under subsection (e)(2) of such
section, shall terminate on the date of enactment of this
Act.
Subtitle E--Medicare, Medicaid, and CHIP Program Integrity Provisions
SEC. 6401. PROVIDER SCREENING AND OTHER ENROLLMENT
REQUIREMENTS UNDER MEDICARE, MEDICAID, AND
CHIP.
(a) Medicare.--Section 1866(j) of the Social Security Act
(42 U.S.C. 1395cc(j)) is amended--
(1) in paragraph (1)(A), by adding at the end the
following: ``Such process shall include screening of
providers and suppliers in accordance with paragraph (2), a
provisional period of enhanced oversight in accordance with
paragraph (3), disclosure requirements in accordance with
paragraph (4), the imposition of temporary
[[Page H2082]]
enrollment moratoria in accordance with paragraph (5), and
the establishment of compliance programs in accordance with
paragraph (6).'';
(2) by redesignating paragraph (2) as paragraph (7); and
(3) by inserting after paragraph (1) the following:
``(2) Provider screening.--
``(A) Procedures.--Not later than 180 days after the date
of enactment of this paragraph, the Secretary, in
consultation with the Inspector General of the Department of
Health and Human Services, shall establish procedures under
which screening is conducted with respect to providers of
medical or other items or services and suppliers under the
program under this title, the Medicaid program under title
XIX, and the CHIP program under title XXI.
``(B) Level of screening.--The Secretary shall determine
the level of screening conducted under this paragraph
according to the risk of fraud, waste, and abuse, as
determined by the Secretary, with respect to the category of
provider of medical or other items or services or supplier.
Such screening--
``(i) shall include a licensure check, which may include
such checks across States; and
``(ii) may, as the Secretary determines appropriate based
on the risk of fraud, waste, and abuse described in the
preceding sentence, include--
``(I) a criminal background check;
``(II) fingerprinting;
``(III) unscheduled and unannounced site visits, including
preenrollment site visits;
``(IV) database checks (including such checks across
States); and
``(V) such other screening as the Secretary determines
appropriate.
``(C) Application fees.--
``(i) Individual providers.--Except as provided in clause
(iii), the Secretary shall impose a fee on each individual
provider of medical or other items or services or supplier
(such as a physician, physician assistant, nurse
practitioner, or clinical nurse specialist) with respect to
which screening is conducted under this paragraph in an
amount equal to--
``(I) for 2010, $200; and
``(II) for 2011 and each subsequent year, the amount
determined under this clause for the preceding year, adjusted
by the percentage change in the consumer price index for all
urban consumers (all items; United States city average) for
the 12-month period ending with June of the previous year.
``(ii) Institutional providers.--Except as provided in
clause (iii), the Secretary shall impose a fee on each
institutional provider of medical or other items or services
or supplier (such as a hospital or skilled nursing facility)
with respect to which screening is conducted under this
paragraph in an amount equal to--
``(I) for 2010, $500; and
``(II) for 2011 and each subsequent year, the amount
determined under this clause for the preceding year, adjusted
by the percentage change in the consumer price index for all
urban consumers (all items; United States city average) for
the 12-month period ending with June of the previous year.
``(iii) Hardship exception; waiver for certain medicaid
providers.--The Secretary may, on a case-by-case basis,
exempt a provider of medical or other items or services or
supplier from the imposition of an application fee under this
subparagraph if the Secretary determines that the imposition
of the application fee would result in a hardship. The
Secretary may waive the application fee under this
subparagraph for providers enrolled in a State Medicaid
program for whom the State demonstrates that imposition of
the fee would impede beneficiary access to care.
``(iv) Use of funds.--Amounts collected as a result of the
imposition of a fee under this subparagraph shall be used by
the Secretary for program integrity efforts, including to
cover the costs of conducting screening under this paragraph
and to carry out this subsection and section 1128J.
``(D) Application and enforcement.--
``(i) New providers of services and suppliers.--The
screening under this paragraph shall apply, in the case of a
provider of medical or other items or services or supplier
who is not enrolled in the program under this title, title
XIX , or title XXI as of the date of enactment of this
paragraph, on or after the date that is 1 year after such
date of enactment.
``(ii) Current providers of services and suppliers.--The
screening under this paragraph shall apply, in the case of a
provider of medical or other items or services or supplier
who is enrolled in the program under this title, title XIX,
or title XXI as of such date of enactment, on or after the
date that is 2 years after such date of enactment.
``(iii) Revalidation of enrollment.--Effective beginning on
the date that is 180 days after such date of enactment, the
screening under this paragraph shall apply with respect to
the revalidation of enrollment of a provider of medical or
other items or services or supplier in the program under this
title, title XIX, or title XXI.
``(iv) Limitation on enrollment and revalidation of
enrollment.--In no case may a provider of medical or other
items or services or supplier who has not been screened under
this paragraph be initially enrolled or reenrolled in the
program under this title, title XIX, or title XXI on or after
the date that is 3 years after such date of enactment.
``(E) Expedited rulemaking.--The Secretary may promulgate
an interim final rule to carry out this paragraph.
``(3) Provisional period of enhanced oversight for new
providers of services and suppliers.--
``(A) In general.--The Secretary shall establish procedures
to provide for a provisional period of not less than 30 days
and not more than 1 year during which new providers of
medical or other items or services and suppliers, as the
Secretary determines appropriate, including categories of
providers or suppliers, would be subject to enhanced
oversight, such as prepayment review and payment caps, under
the program under this title, the Medicaid program under
title XIX. and the CHIP program under title XXI.
``(B) Implementation.--The Secretary may establish by
program instruction or otherwise the procedures under this
paragraph.
``(4) Increased disclosure requirements.--
``(A) Disclosure.--A provider of medical or other items or
services or supplier who submits an application for
enrollment or revalidation of enrollment in the program under
this title, title XIX, or title XXI on or after the date that
is 1 year after the date of enactment of this paragraph shall
disclose (in a form and manner and at such time as determined
by the Secretary) any current or previous affiliation
(directly or indirectly) with a provider of medical or other
items or services or supplier that has uncollected debt, has
been or is subject to a payment suspension under a Federal
health care program (as defined in section 1128B(f)), has
been excluded from participation under the program under this
title, the Medicaid program under title XIX, or the CHIP
program under title XXI, or has had its billing privileges
denied or revoked.
``(B) Authority to deny enrollment.--If the Secretary
determines that such previous affiliation poses an undue risk
of fraud, waste, or abuse, the Secretary may deny such
application. Such a denial shall be subject to appeal in
accordance with paragraph (7).
``(5) Authority to adjust payments of providers of services
and suppliers with the same tax identification number for
past-due obligations.--
``(A) In general.--Notwithstanding any other provision of
this title, in the case of an applicable provider of services
or supplier, the Secretary may make any necessary adjustments
to payments to the applicable provider of services or
supplier under the program under this title in order to
satisfy any past-due obligations described in subparagraph
(B)(ii) of an obligated provider of services or supplier.
``(B) Definitions.--In this paragraph:
``(i) In general.--The term `applicable provider of
services or supplier' means a provider of services or
supplier that has the same taxpayer identification number
assigned under section 6109 of the Internal Revenue Code of
1986 as is assigned to the obligated provider of services or
supplier under such section, regardless of whether the
applicable provider of services or supplier is assigned a
different billing number or national provider identification
number under the program under this title than is assigned to
the obligated provider of services or supplier.
``(ii) Obligated provider of services or supplier.--The
term `obligated provider of services or supplier' means a
provider of services or supplier that owes a past-due
obligation under the program under this title (as determined
by the Secretary).
``(6) Temporary moratorium on enrollment of new
providers.--
``(A) In general.--The Secretary may impose a temporary
moratorium on the enrollment of new providers of services and
suppliers, including categories of providers of services and
suppliers, in the program under this title, under the
Medicaid program under title XIX, or under the CHIP program
under title XXI if the Secretary determines such moratorium
is necessary to prevent or combat fraud, waste, or abuse
under either such program.
``(B) Limitation on review.--There shall be no judicial
review under section 1869, section 1878, or otherwise, of a
temporary moratorium imposed under subparagraph (A).
``(7) Compliance programs.--
``(A) In general.--On or after the date of implementation
determined by the Secretary under subparagraph (C), a
provider of medical or other items or services or supplier
within a particular industry sector or category shall, as a
condition of enrollment in the program under this title,
title XIX, or title XXI, establish a compliance program that
contains the core elements established under subparagraph (B)
with respect to that provider or supplier and industry or
category.
``(B) Establishment of core elements.--The Secretary, in
consultation with the Inspector General of the Department of
Health and Human Services, shall establish core elements for
a compliance program under subparagraph (A) for providers or
suppliers within a particular industry or category.
``(C) Timeline for implementation.--The Secretary shall
determine the timeline for the establishment of the core
elements under subparagraph (B) and the date of the
implementation of subparagraph (A) for providers or suppliers
within a particular industry or category. The Secretary
shall, in determining such date of implementation, consider
the extent to which the adoption of compliance programs by a
provider of medical or other items or services or supplier is
widespread in a particular industry sector or with respect to
a particular provider or supplier category.''.
(b) Medicaid.--
(1) State plan amendment.--Section 1902(a) of the Social
Security Act (42 U.S.C. 1396a(a)), as amended by section
4302(b), is amended--
(A) in subsection (a)--
(i) by striking ``and'' at the end of paragraph (75);
(ii) by striking the period at the end of paragraph (76)
and inserting a semicolon; and
(iii) by inserting after paragraph (76) the following:
``(77) provide that the State shall comply with provider
and supplier screening, oversight, and reporting requirements
in accordance with subsection (ii);''; and
[[Page H2083]]
(B) by adding at the end the following:
``(ii) Provider and Supplier Screening, Oversight, and
Reporting Requirements.--For purposes of subsection (a)(77),
the requirements of this subsection are the following:
``(1) Screening.--The State complies with the process for
screening providers and suppliers under this title, as
established by the Secretary under section 1886(j)(2).
``(2) Provisional period of enhanced oversight for new
providers and suppliers.--The State complies with procedures
to provide for a provisional period of enhanced oversight for
new providers and suppliers under this title, as established
by the Secretary under section 1886(j)(3).
``(3) Disclosure requirements.--The State requires
providers and suppliers under the State plan or under a
waiver of the plan to comply with the disclosure requirements
established by the Secretary under section 1886(j)(4).
``(4) Temporary moratorium on enrollment of new providers
or suppliers.--
``(A) Temporary moratorium imposed by the secretary.--
``(i) In general.--Subject to clause (ii), the State
complies with any temporary moratorium on the enrollment of
new providers or suppliers imposed by the Secretary under
section 1886(j)(6).
``(ii) Exception.--A State shall not be required to comply
with a temporary moratorium described in clause (i) if the
State determines that the imposition of such temporary
moratorium would adversely impact beneficiaries' access to
medical assistance.
``(B) Moratorium on enrollment of providers and
suppliers.--At the option of the State, the State imposes,
for purposes of entering into participation agreements with
providers or suppliers under the State plan or under a waiver
of the plan, periods of enrollment moratoria, or numerical
caps or other limits, for providers or suppliers identified
by the Secretary as being at high-risk for fraud, waste, or
abuse as necessary to combat fraud, waste, or abuse, but only
if the State determines that the imposition of any such
period, cap, or other limits would not adversely impact
beneficiaries' access to medical assistance.
``(5) Compliance programs.--The State requires providers
and suppliers under the State plan or under a waiver of the
plan to establish, in accordance with the requirements of
section 1866(j)(7), a compliance program that contains the
core elements established under subparagraph (B) of that
section 1866(j)(7) for providers or suppliers within a
particular industry or category.
``(6) Reporting of adverse provider actions.--The State
complies with the national system for reporting criminal and
civil convictions, sanctions, negative licensure actions, and
other adverse provider actions to the Secretary, through the
Administrator of the Centers for Medicare & Medicaid
Services, in accordance with regulations of the Secretary.
``(7) Enrollment and npi of ordering or referring
providers.--The State requires--
``(A) all ordering or referring physicians or other
professionals to be enrolled under the State plan or under a
waiver of the plan as a participating provider; and
``(B) the national provider identifier of any ordering or
referring physician or other professional to be specified on
any claim for payment that is based on an order or referral
of the physician or other professional.
``(8) Other state oversight.--Nothing in this subsection
shall be interpreted to preclude or limit the ability of a
State to engage in provider and supplier screening or
enhanced provider and supplier oversight activities beyond
those required by the Secretary.''.
(2) Disclosure of medicare terminated providers and
suppliers to states.--The Administrator of the Centers for
Medicare & Medicaid Services shall establish a process for
making available to the each State agency with responsibility
for administering a State Medicaid plan (or a waiver of such
plan) under title XIX of the Social Security Act or a child
health plan under title XXI the name, national provider
identifier, and other identifying information for any
provider of medical or other items or services or supplier
under the Medicare program under title XVIII or under the
CHIP program under title XXI that is terminated from
participation under that program within 30 days of the
termination (and, with respect to all such providers or
suppliers who are terminated from the Medicare program on the
date of enactment of this Act, within 90 days of such date).
(3) Conforming amendment.--Section 1902(a)(23) of the
Social Security Act (42 U.S.C. 1396a), is amended by
inserting before the semicolon at the end the following: ``or
by a provider or supplier to which a moratorium under
subsection (ii)(4) is applied during the period of such
moratorium''.
(c) CHIP.--Section 2107(e)(1) of the Social Security Act
(42 U.S.C. 1397gg(e)(1)), as amended by section 2101(d), is
amended--
(1) by redesignating subparagraphs (D) through (M) as
subparagraphs (E) through (N), respectively; and
(2) by inserting after subparagraph (C), the following:
``(D) Subsections (a)(77) and (ii) of section 1902
(relating to provider and supplier screening, oversight, and
reporting requirements).''.
SEC. 6402. ENHANCED MEDICARE AND MEDICAID PROGRAM INTEGRITY
PROVISIONS.
(a) In General.--Part A of title XI of the Social Security
Act (42 U.S.C. 1301 et seq.), as amended by sections 6002,
6004, and 6102, is amended by inserting after section 1128I
the following new section:
``SEC. 1128J. MEDICARE AND MEDICAID PROGRAM INTEGRITY
PROVISIONS.
``(a) Data Matching.--
``(1) Integrated data repository.--
``(A) Inclusion of certain data.--
``(i) In general.--The Integrated Data Repository of the
Centers for Medicare & Medicaid Services shall include, at a
minimum, claims and payment data from the following:
``(I) The programs under titles XVIII and XIX (including
parts A, B, C, and D of title XVIII).
``(II) The program under title XXI.
``(III) Health-related programs administered by the
Secretary of Veterans Affairs.
``(IV) Health-related programs administered by the
Secretary of Defense.
``(V) The program of old-age, survivors, and disability
insurance benefits established under title II.
``(VI) The Indian Health Service and the Contract Health
Service program.
``(ii) Priority for inclusion of certain data.--Inclusion
of the data described in subclause (I) of such clause in the
Integrated Data Repository shall be a priority. Data
described in subclauses (II) through (VI) of such clause
shall be included in the Integrated Data Repository as
appropriate.
``(B) Data sharing and matching.--
``(i) In general.--The Secretary shall enter into
agreements with the individuals described in clause (ii)
under which such individuals share and match data in the
system of records of the respective agencies of such
individuals with data in the system of records of the
Department of Health and Human Services for the purpose of
identifying potential fraud, waste, and abuse under the
programs under titles XVIII and XIX.
``(ii) Individuals described.--The following individuals
are described in this clause:
``(I) The Commissioner of Social Security.
``(II) The Secretary of Veterans Affairs.
``(III) The Secretary of Defense.
``(IV) The Director of the Indian Health Service.
``(iii) Definition of system of records.--For purposes of
this paragraph, the term `system of records' has the meaning
given such term in section 552a(a)(5) of title 5, United
States Code.
``(2) Access to claims and payment databases.--For purposes
of conducting law enforcement and oversight activities and to
the extent consistent with applicable information, privacy,
security, and disclosure laws, including the regulations
promulgated under the Health Insurance Portability and
Accountability Act of 1996 and section 552a of title 5,
United States Code, and subject to any information systems
security requirements under such laws or otherwise required
by the Secretary, the Inspector General of the Department of
Health and Human Services and the Attorney General shall have
access to claims and payment data of the Department of Health
and Human Services and its contractors related to titles
XVIII, XIX, and XXI.
``(b) OIG Authority To Obtain Information.--
``(1) In general.--Notwithstanding and in addition to any
other provision of law, the Inspector General of the
Department of Health and Human Services may, for purposes of
protecting the integrity of the programs under titles XVIII
and XIX, obtain information from any individual (including a
beneficiary provided all applicable privacy protections are
followed) or entity that--
``(A) is a provider of medical or other items or services,
supplier, grant recipient, contractor, or subcontractor; or
``(B) directly or indirectly provides, orders,
manufactures, distributes, arranges for, prescribes,
supplies, or receives medical or other items or services
payable by any Federal health care program (as defined in
section 1128B(f)) regardless of how the item or service is
paid for, or to whom such payment is made.
``(2) Inclusion of certain information.--Information which
the Inspector General may obtain under paragraph (1) includes
any supporting documentation necessary to validate claims for
payment or payments under title XVIII or XIX, including a
prescribing physician's medical records for an individual who
is prescribed an item or service which is covered under part
B of title XVIII, a covered part D drug (as defined in
section 1860D-2(e)) for which payment is made under an MA-PD
plan under part C of such title, or a prescription drug plan
under part D of such title, and any records necessary for
evaluation of the economy, efficiency, and effectiveness of
the programs under titles XVIII and XIX.
``(c) Administrative Remedy for Knowing Participation by
Beneficiary in Health Care Fraud Scheme.--
``(1) In general.--In addition to any other applicable
remedies, if an applicable individual has knowingly
participated in a Federal health care fraud offense or a
conspiracy to commit a Federal health care fraud offense, the
Secretary shall impose an appropriate administrative penalty
commensurate with the offense or conspiracy.
``(2) Applicable individual.--For purposes of paragraph
(1), the term `applicable individual' means an individual--
``(A) entitled to, or enrolled for, benefits under part A
of title XVIII or enrolled under part B of such title;
``(B) eligible for medical assistance under a State plan
under title XIX or under a waiver of such plan; or
``(C) eligible for child health assistance under a child
health plan under title XXI.
``(d) Reporting and Returning of Overpayments.--
``(1) In general.--If a person has received an overpayment,
the person shall--
``(A) report and return the overpayment to the Secretary,
the State, an intermediary, a carrier, or a contractor, as
appropriate, at the correct address; and
``(B) notify the Secretary, State, intermediary, carrier,
or contractor to whom the overpayment
[[Page H2084]]
was returned in writing of the reason for the overpayment.
``(2) Deadline for reporting and returning overpayments.--
An overpayment must be reported and returned under paragraph
(1) by the later of--
``(A) the date which is 60 days after the date on which the
overpayment was identified; or
``(B) the date any corresponding cost report is due, if
applicable.
``(3) Enforcement.--Any overpayment retained by a person
after the deadline for reporting and returning the
overpayment under paragraph (2) is an obligation (as defined
in section 3729(b)(3) of title 31, United States Code) for
purposes of section 3729 of such title.
``(4) Definitions.--In this subsection:
``(A) Knowing and knowingly.--The terms `knowing' and
`knowingly' have the meaning given those terms in section
3729(b) of title 31, United States Code.
``(B) Overpayment.--The term ``overpayment'' means any
funds that a person receives or retains under title XVIII or
XIX to which the person, after applicable reconciliation, is
not entitled under such title.
``(C) Person.--
``(i) In general.--The term `person' means a provider of
services, supplier, medicaid managed care organization (as
defined in section 1903(m)(1)(A)), Medicare Advantage
organization (as defined in section 1859(a)(1)), or PDP
sponsor (as defined in section 1860D-41(a)(13)).
``(ii) Exclusion.--Such term does not include a
beneficiary.
``(e) Inclusion of National Provider Identifier on All
Applications and Claims.--The Secretary shall promulgate a
regulation that requires, not later than January 1, 2011, all
providers of medical or other items or services and suppliers
under the programs under titles XVIII and XIX that qualify
for a national provider identifier to include their national
provider identifier on all applications to enroll in such
programs and on all claims for payment submitted under such
programs.''.
(b) Access to Data.--
(1) Medicare part d.--Section 1860D-15(f)(2) of the Social
Security Act (42 U.S.C. 1395w-116(f)(2)) is amended by
striking ``may be used by'' and all that follows through the
period at the end and inserting ``may be used--
``(A) by officers, employees, and contractors of the
Department of Health and Human Services for the purposes of,
and to the extent necessary in--
``(i) carrying out this section; and
``(ii) conducting oversight, evaluation, and enforcement
under this title; and
``(B) by the Attorney General and the Comptroller General
of the United States for the purposes of, and to the extent
necessary in, carrying out health oversight activities.''.
(2) Data matching.--Section 552a(a)(8)(B) of title 5,
United States Code, is amended--
(A) in clause (vii), by striking ``or'' at the end;
(B) in clause (viii), by inserting ``or'' after the
semicolon; and
(C) by adding at the end the following new clause:
``(ix) matches performed by the Secretary of Health and
Human Services or the Inspector General of the Department of
Health and Human Services with respect to potential fraud,
waste, and abuse, including matches of a system of records
with non-Federal records;''.
(3) Matching agreements with the commissioner of social
security.--Section 205(r) of the Social Security Act (42
U.S.C. 405(r)) is amended by adding at the end the following
new paragraph:
``(9)(A) The Commissioner of Social Security shall, upon
the request of the Secretary or the Inspector General of the
Department of Health and Human Services--
``(i) enter into an agreement with the Secretary or such
Inspector General for the purpose of matching data in the
system of records of the Social Security Administration and
the system of records of the Department of Health and Human
Services; and
``(ii) include in such agreement safeguards to assure the
maintenance of the confidentiality of any information
disclosed.
``(B) For purposes of this paragraph, the term `system of
records' has the meaning given such term in section
552a(a)(5) of title 5, United States Code.''.
(c) Withholding of Federal Matching Payments for States
That Fail To Report Enrollee Encounter Data in the Medicaid
Statistical Information System.--Section 1903(i) of the
Social Security Act (42 U.S.C. 1396b(i)) is amended--
(1) in paragraph (23), by striking ``or'' at the end;
(2) in paragraph (24), by striking the period at the end
and inserting ``; or''; and
(3) by adding at the end the following new paragraph:.
``(25) with respect to any amounts expended for medical
assistance for individuals for whom the State does not report
enrollee encounter data (as defined by the Secretary) to the
Medicaid Statistical Information System (MSIS) in a timely
manner (as determined by the Secretary).''.
(d) Permissive Exclusions and Civil Monetary Penalties.--
(1) Permissive exclusions.--Section 1128(b) of the Social
Security Act (42 U.S.C. 1320a-7(b)) is amended by adding at
the end the following new paragraph:
``(16) Making false statements or misrepresentation of
material facts.--Any individual or entity that knowingly
makes or causes to be made any false statement, omission, or
misrepresentation of a material fact in any application,
agreement, bid, or contract to participate or enroll as a
provider of services or supplier under a Federal health care
program (as defined in section 1128B(f)), including Medicare
Advantage organizations under part C of title XVIII,
prescription drug plan sponsors under part D of title XVIII,
medicaid managed care organizations under title XIX, and
entities that apply to participate as providers of services
or suppliers in such managed care organizations and such
plans.''.
(2) Civil monetary penalties.--
(A) In general.--Section 1128A(a) of the Social Security
Act (42 U.S.C. 1320a-7a(a)) is amended--
(i) in paragraph (1)(D), by striking ``was excluded'' and
all that follows through the period at the end and inserting
``was excluded from the Federal health care program (as
defined in section 1128B(f)) under which the claim was made
pursuant to Federal law.'';
(ii) in paragraph (6), by striking ``or'' at the end;
(iii) by inserting after paragraph (7), the following new
paragraphs:
``(8) orders or prescribes a medical or other item or
service during a period in which the person was excluded from
a Federal health care program (as so defined), in the case
where the person knows or should know that a claim for such
medical or other item or service will be made under such a
program;
``(9) knowingly makes or causes to be made any false
statement, omission, or misrepresentation of a material fact
in any application, bid, or contract to participate or enroll
as a provider of services or a supplier under a Federal
health care program (as so defined), including Medicare
Advantage organizations under part C of title XVIII,
prescription drug plan sponsors under part D of title XVIII,
medicaid managed care organizations under title XIX, and
entities that apply to participate as providers of services
or suppliers in such managed care organizations and such
plans;
``(10) knows of an overpayment (as defined in paragraph (4)
of section 1128J(d)) and does not report and return the
overpayment in accordance with such section;'';
(iv) in the first sentence--
(I) by striking the ``or'' after ``prohibited relationship
occurs;''; and
(II) by striking ``act)'' and inserting ``act; or in cases
under paragraph (9), $50,000 for each false statement or
misrepresentation of a material fact)''; and
(v) in the second sentence, by striking ``purpose)'' and
inserting ``purpose; or in cases under paragraph (9), an
assessment of not more than 3 times the total amount claimed
for each item or service for which payment was made based
upon the application containing the false statement or
misrepresentation of a material fact)''.
(B) Clarification of treatment of certain charitable and
other innocuous programs.--Section 1128A(i)(6) of the Social
Security Act (42 U.S.C. 1320a-7a(i)(6)) is amended--
(i) in subparagraph (C), by striking ``or'' at the end;
(ii) in subparagraph (D), as redesignated by section
4331(e) of the Balanced Budget Act of 1997 (Public Law 105-
33), by striking the period at the end and inserting a
semicolon;
(iii) by redesignating subparagraph (D), as added by
section 4523(c) of such Act, as subparagraph (E) and striking
the period at the end and inserting ``; or''; and
(iv) by adding at the end the following new subparagraphs:
``(F) any other remuneration which promotes access to care
and poses a low risk of harm to patients and Federal health
care programs (as defined in section 1128B(f) and designated
by the Secretary under regulations);
``(G) the offer or transfer of items or services for free
or less than fair market value by a person, if--
``(i) the items or services consist of coupons, rebates, or
other rewards from a retailer;
``(ii) the items or services are offered or transferred on
equal terms available to the general public, regardless of
health insurance status; and
``(iii) the offer or transfer of the items or services is
not tied to the provision of other items or services
reimbursed in whole or in part by the program under title
XVIII or a State health care program (as defined in section
1128(h));
``(H) the offer or transfer of items or services for free
or less than fair market value by a person, if--
``(i) the items or services are not offered as part of any
advertisement or solicitation;
``(ii) the items or services are not tied to the provision
of other services reimbursed in whole or in part by the
program under title XVIII or a State health care program (as
so defined);
``(iii) there is a reasonable connection between the items
or services and the medical care of the individual; and
``(iv) the person provides the items or services after
determining in good faith that the individual is in financial
need; or
``(I) effective on a date specified by the Secretary (but
not earlier than January 1, 2011), the waiver by a PDP
sponsor of a prescription drug plan under part D of title
XVIII or an MA organization offering an MA-PD plan under part
C of such title of any copayment for the first fill of a
covered part D drug (as defined in section 1860D-2(e)) that
is a generic drug for individuals enrolled in the
prescription drug plan or MA-PD plan, respectively.''.
(e) Testimonial Subpoena Authority in Exclusion-only
Cases.--Section 1128(f) of the Social Security Act (42 U.S.C.
1320a-7(f)) is amended by adding at the end the following new
paragraph:
``(4) The provisions of subsections (d) and (e) of section
205 shall apply with respect to this section to the same
extent as they are applicable with respect to title II. The
Secretary may delegate the authority granted by section
205(d) (as made applicable to this section) to the Inspector
General of the Department of Health and Human Services for
purposes of any investigation under this section.''.
[[Page H2085]]
(f) Health Care Fraud.--
(1) Kickbacks.--Section 1128B of the Social Security Act
(42 U.S.C. 1320a-7b) is amended by adding at the end the
following new subsection:
``(g) In addition to the penalties provided for in this
section or section 1128A, a claim that includes items or
services resulting from a violation of this section
constitutes a false or fraudulent claim for purposes of
subchapter III of chapter 37 of title 31, United States
Code.''.
(2) Revising the intent requirement.--Section 1128B of the
Social Security Act (42 U.S.C. 1320a-7b), as amended by
paragraph (1), is amended by adding at the end the following
new subsection:
``(h) With respect to violations of this section, a person
need not have actual knowledge of this section or specific
intent to commit a violation of this section.''.
(g) Surety Bond Requirements.--
(1) Durable medical equipment.--Section 1834(a)(16)(B) of
the Social Security Act (42 U.S.C. 1395m(a)(16)(B)) is
amended by inserting ``that the Secretary determines is
commensurate with the volume of the billing of the supplier''
before the period at the end.
(2) Home health agencies.--Section 1861(o)(7)(C) of the
Social Security Act (42 U.S.C. 1395x(o)(7)(C)) is amended by
inserting ``that the Secretary determines is commensurate
with the volume of the billing of the home health agency''
before the semicolon at the end.
(3) Requirements for certain other providers of services
and suppliers.--Section 1862 of the Social Security Act (42
U.S.C. 1395y) is amended by adding at the end the following
new subsection:
``(n) Requirement of a Surety Bond for Certain Providers of
Services and Suppliers.--
``(1) In general.--The Secretary may require a provider of
services or supplier described in paragraph (2) to provide
the Secretary on a continuing basis with a surety bond in a
form specified by the Secretary in an amount (not less than
$50,000) that the Secretary determines is commensurate with
the volume of the billing of the provider of services or
supplier. The Secretary may waive the requirement of a bond
under the preceding sentence in the case of a provider of
services or supplier that provides a comparable surety bond
under State law.
``(2) Provider of services or supplier described.--A
provider of services or supplier described in this paragraph
is a provider of services or supplier the Secretary
determines appropriate based on the level of risk involved
with respect to the provider of services or supplier, and
consistent with the surety bond requirements under sections
1834(a)(16)(B) and 1861(o)(7)(C).''.
(h) Suspension of Medicare and Medicaid Payments Pending
Investigation of Credible Allegations of Fraud.--
(1) Medicare.--Section 1862 of the Social Security Act (42
U.S.C. 1395y), as amended by subsection (g)(3), is amended by
adding at the end the following new subsection:
``(o) Suspension of Payments Pending Investigation of
Credible Allegations of Fraud.--
``(1) In general.--The Secretary may suspend payments to a
provider of services or supplier under this title pending an
investigation of a credible allegation of fraud against the
provider of services or supplier, unless the Secretary
determines there is good cause not to suspend such payments.
``(2) Consultation.--The Secretary shall consult with the
Inspector General of the Department of Health and Human
Services in determining whether there is a credible
allegation of fraud against a provider of services or
supplier.
``(3) Promulgation of regulations.--The Secretary shall
promulgate regulations to carry out this subsection and
section 1903(i)(2)(C).''.
(2) Medicaid.--Section 1903(i)(2) of such Act (42 U.S.C.
1396b(i)(2)) is amended--
(A) in subparagraph (A), by striking ``or'' at the end; and
(B) by inserting after subparagraph (B), the following:
``(C) by any individual or entity to whom the State has
failed to suspend payments under the plan during any period
when there is pending an investigation of a credible
allegation of fraud against the individual or entity, as
determined by the State in accordance with regulations
promulgated by the Secretary for purposes of section 1862(o)
and this subparagraph, unless the State determines in
accordance with such regulations there is good cause not to
suspend such payments; or''.
(i) Increased Funding To Fight Fraud and Abuse.--
(1) In general.--Section 1817(k) of the Social Security Act
(42 U.S.C. 1395i(k)) is amended--
(A) by adding at the end the following new paragraph:
``(7) Additional funding.--In addition to the funds
otherwise appropriated to the Account from the Trust Fund
under paragraphs (3) and (4) and for purposes described in
paragraphs (3)(C) and (4)(A), there are hereby appropriated
an additional $10,000,000 to such Account from such Trust
Fund for each of fiscal years 2011 through 2020. The funds
appropriated under this paragraph shall be allocated in the
same proportion as the total funding appropriated with
respect to paragraphs (3)(A) and (4)(A) was allocated with
respect to fiscal year 2010, and shall be available without
further appropriation until expended.''; and
(B) in paragraph (4)(A), by inserting ``until expended''
after ``appropriation''.
(2) Indexing of amounts appropriated.--
(A) Departments of health and human services and justice.--
Section 1817(k)(3)(A)(i) of the Social Security Act (42
U.S.C. 1395i(k)(3)(A)(i)) is amended--
(i) in subclause (III), by inserting ``and'' at the end;
(ii) in subclause (IV)--
(I) by striking ``for each of fiscal years 2007, 2008,
2009, and 2010'' and inserting ``for each fiscal year after
fiscal year 2006''; and
(II) by striking ``; and'' and inserting a period; and
(iii) by striking subclause (V).
(B) Office of the inspector general of the department of
health and human services.--Section 1817(k)(3)(A)(ii) of such
Act (42 U.S.C. 1395i(k)(3)(A)(ii)) is amended--
(i) in subclause (VIII), by inserting ``and'' at the end;
(ii) in subclause (IX)--
(I) by striking ``for each of fiscal years 2008, 2009, and
2010'' and inserting ``for each fiscal year after fiscal year
2007''; and
(II) by striking ``; and'' and inserting a period; and
(iii) by striking subclause (X).
(C) Federal bureau of investigation.--Section 1817(k)(3)(B)
of the Social Security Act (42 U.S.C. 1395i(k)(3)(B)) is
amended--
(i) in clause (vii), by inserting ``and'' at the end;
(ii) in clause (viii)--
(I) by striking ``for each of fiscal years 2007, 2008,
2009, and 2010'' and inserting ``for each fiscal year after
fiscal year 2006''; and
(II) by striking ``; and'' and inserting a period; and
(iii) by striking clause (ix).
(D) Medicare integrity program.--Section 1817(k)(4)(C) of
the Social Security Act (42 U.S.C. 1395i(k)(4)(C)) is amended
by adding at the end the following new clause:
``(ii) For each fiscal year after 2010, by the percentage
increase in the consumer price index for all urban consumers
(all items; United States city average) over the previous
year.''.
(j) Medicare Integrity Program and Medicaid Integrity
Program.--
(1) Medicare integrity program.--
(A) Requirement to provide performance statistics.--Section
1893(c) of the Social Security Act (42 U.S.C. 1395ddd(c)) is
amended--
(i) in paragraph (3), by striking ``and'' at the end;
(ii) by redesignating paragraph (4) as paragraph (5); and
(iii) by inserting after paragraph (3) the following new
paragraph:
``(4) the entity agrees to provide the Secretary and the
Inspector General of the Department of Health and Human
Services with such performance statistics (including the
number and amount of overpayments recovered, the number of
fraud referrals, and the return on investment of such
activities by the entity) as the Secretary or the Inspector
General may request; and''.
(B) Evaluations and annual report.--Section 1893 of the
Social Security Act (42 U.S.C. 1395ddd) is amended by adding
at the end the following new subsection:
``(i) Evaluations and Annual Report.--
``(1) Evaluations.--The Secretary shall conduct evaluations
of eligible entities which the Secretary contracts with under
the Program not less frequently than every 3 years.
``(2) Annual report.--Not later than 180 days after the end
of each fiscal year (beginning with fiscal year 2011), the
Secretary shall submit a report to Congress which
identifies--
``(A) the use of funds, including funds transferred from
the Federal Hospital Insurance Trust Fund under section 1817
and the Federal Supplementary Insurance Trust Fund under
section 1841, to carry out this section; and
``(B) the effectiveness of the use of such funds.''.
(C) Flexibility in pursuing fraud and abuse.--Section
1893(a) of the Social Security Act (42 U.S.C. 1395ddd(a)) is
amended by inserting ``, or otherwise,'' after ``entities''.
(2) Medicaid integrity program.--
(A) Requirement to provide performance statistics.--Section
1936(c)(2) of the Social Security Act (42 U.S.C. 1396u-
6(c)(2)) is amended--
(i) by redesignating subparagraph (D) as subparagraph (E);
and
(ii) by inserting after subparagraph (C) the following new
subparagraph:
``(D) The entity agrees to provide the Secretary and the
Inspector General of the Department of Health and Human
Services with such performance statistics (including the
number and amount of overpayments recovered, the number of
fraud referrals, and the return on investment of such
activities by the entity) as the Secretary or the Inspector
General may request.''.
(B) Evaluations and annual report.--Section 1936(e) of the
Social Security Act (42 U.S.C. 1396u-7(e)) is amended--
(i) by redesignating paragraph (4) as paragraph (5); and
(ii) by inserting after paragraph (3) the following new
paragraph:
``(4) Evaluations.--The Secretary shall conduct evaluations
of eligible entities which the Secretary contracts with under
the Program not less frequently than every 3 years.''.
(k) Expanded Application of Hardship Waivers for
Exclusions.--Section 1128(c)(3)(B) of the Social Security Act
(42 U.S.C. 1320a-7(c)(3)(B)) is amended by striking
``individuals entitled to benefits under part A of title
XVIII or enrolled under part B of such title, or both'' and
inserting ``beneficiaries (as defined in section 1128A(i)(5))
of that program''.
SEC. 6403. ELIMINATION OF DUPLICATION BETWEEN THE HEALTHCARE
INTEGRITY AND PROTECTION DATA BANK AND THE
NATIONAL PRACTITIONER DATA BANK.
(a) Information Reported by Federal Agencies and Health
Plans.--Section 1128E of the Social Security Act (42 U.S.C.
1320a-7e) is amended--
(1) by striking subsection (a) and inserting the following:
``(a) In General.--The Secretary shall maintain a national
health care fraud and abuse data collection program under
this section for
[[Page H2086]]
the reporting of certain final adverse actions (not including
settlements in which no findings of liability have been made)
against health care providers, suppliers, or practitioners as
required by subsection (b), with access as set forth in
subsection (d), and shall furnish the information collected
under this section to the National Practitioner Data Bank
established pursuant to the Health Care Quality Improvement
Act of 1986 (42 U.S.C. 11101 et seq.).'';
(2) by striking subsection (d) and inserting the following:
``(d) Access to Reported Information.--
``(1) Availability.--The information collected under this
section shall be available from the National Practitioner
Data Bank to the agencies, authorities, and officials which
are provided under section 1921(b) information reported under
section 1921(a).
``(2) Fees for disclosure.--The Secretary may establish or
approve reasonable fees for the disclosure of information
under this section. The amount of such a fee may not exceed
the costs of processing the requests for disclosure and of
providing such information. Such fees shall be available to
the Secretary to cover such costs.'';
(3) by striking subsection (f) and inserting the following:
``(f) Appropriate Coordination.--In implementing this
section, the Secretary shall provide for the maximum
appropriate coordination with part B of the Health Care
Quality Improvement Act of 1986 (42 U.S.C. 11131 et seq.) and
section 1921.''; and
(4) in subsection (g)--
(A) in paragraph (1)(A)--
(i) in clause (iii)--
(I) by striking ``or State'' each place it appears;
(II) by redesignating subclauses (II) and (III) as
subclauses (III) and (IV), respectively; and
(III) by inserting after subclause (I) the following new
subclause:
``(II) any dismissal or closure of the proceedings by
reason of the provider, supplier, or practitioner
surrendering their license or leaving the State or
jurisdiction''; and
(ii) by striking clause (iv) and inserting the following:
``(iv) Exclusion from participation in a Federal health
care program (as defined in section 1128B(f)).'';
(B) in paragraph (3)--
(i) by striking subparagraphs (D) and (E); and
(ii) by redesignating subparagraph (F) as subparagraph (D);
and
(C) in subparagraph (D) (as so redesignated), by striking
``or State''.
(b) Information Reported by State Law or Fraud Enforcement
Agencies.--Section 1921 of the Social Security Act (42 U.S.C.
1396r-2) is amended--
(1) in subsection (a)--
(A) in paragraph (1)--
(i) by striking ``system.--The State'' and all that follows
through the semicolon and inserting system.--
``(A) Licensing or certification actions.--The State must
have in effect a system of reporting the following
information with respect to formal proceedings (as defined by
the Secretary in regulations) concluded against a health care
practitioner or entity by a State licensing or certification
agency:'';
(ii) by redesignating subparagraphs (A) through (D) as
clauses (i) through (iv), respectively, and indenting
appropriately;
(iii) in subparagraph (A)(iii) (as so redesignated)--
(I) by striking ``the license of'' and inserting ``license
or the right to apply for, or renew, a license by''; and
(II) by inserting ``nonrenewability,'' after ``voluntary
surrender,''; and
(iv) by adding at the end the following new subparagraph:
``(B) Other final adverse actions.--The State must have in
effect a system of reporting information with respect to any
final adverse action (not including settlements in which no
findings of liability have been made) taken against a health
care provider, supplier, or practitioner by a State law or
fraud enforcement agency.''; and
(B) in paragraph (2), by striking ``the authority described
in paragraph (1)'' and inserting ``a State licensing or
certification agency or State law or fraud enforcement
agency'';
(2) in subsection (b)--
(A) by striking paragraph (2) and inserting the following:
``(2) to State licensing or certification agencies and
Federal agencies responsible for the licensing and
certification of health care providers, suppliers, and
licensed health care practitioners;'';
(B) in each of paragraphs (4) and (6), by inserting ``, but
only with respect to information provided pursuant to
subsection (a)(1)(A)'' before the comma at the end;
(C) by striking paragraph (5) and inserting the following:
``(5) to State law or fraud enforcement agencies,'';
(D) by redesignating paragraphs (7) and (8) as paragraphs
(8) and (9), respectively; and
(E) by inserting after paragraph (6) the following new
paragraph:
``(7) to health plans (as defined in section 1128C(c));'';
(3) by redesignating subsection (d) as subsection (h), and
by inserting after subsection (c) the following new
subsections:
``(d) Disclosure and Correction of Information.--
``(1) Disclosure.--With respect to information reported
pursuant to subsection (a)(1), the Secretary shall--
``(A) provide for disclosure of the information, upon
request, to the health care practitioner who, or the entity
that, is the subject of the information reported; and
``(B) establish procedures for the case where the health
care practitioner or entity disputes the accuracy of the
information reported.
``(2) Corrections.--Each State licensing or certification
agency and State law or fraud enforcement agency shall report
corrections of information already reported about any formal
proceeding or final adverse action described in subsection
(a), in such form and manner as the Secretary prescribes by
regulation.
``(e) Fees for Disclosure.--The Secretary may establish or
approve reasonable fees for the disclosure of information
under this section. The amount of such a fee may not exceed
the costs of processing the requests for disclosure and of
providing such information. Such fees shall be available to
the Secretary to cover such costs.
``(f) Protection From Liability for Reporting.--No person
or entity, including any agency designated by the Secretary
in subsection (b), shall be held liable in any civil action
with respect to any reporting of information as required
under this section, without knowledge of the falsity of the
information contained in the report.
``(g) References.--For purposes of this section:
``(1) State licensing or certification agency.--The term
`State licensing or certification agency' includes any
authority of a State (or of a political subdivision thereof)
responsible for the licensing of health care practitioners
(or any peer review organization or private accreditation
entity reviewing the services provided by health care
practitioners) or entities.
``(2) State law or fraud enforcement agency.--The term
`State law or fraud enforcement agency' includes--
``(A) a State law enforcement agency; and
``(B) a State medicaid fraud control unit (as defined in
section 1903(q)).
``(3) Final adverse action.--
``(A) In general.--Subject to subparagraph (B), the term
`final adverse action' includes--
``(i) civil judgments against a health care provider,
supplier, or practitioner in State court related to the
delivery of a health care item or service;
``(ii) State criminal convictions related to the delivery
of a health care item or service;
``(iii) exclusion from participation in State health care
programs (as defined in section 1128(h));
``(iv) any licensing or certification action described in
subsection (a)(1)(A) taken against a supplier by a State
licensing or certification agency; and
``(v) any other adjudicated actions or decisions that the
Secretary shall establish by regulation.
``(B) Exception.--Such term does not include any action
with respect to a malpractice claim.''; and
(4) in subsection (h), as so redesignated, by striking
``The Secretary'' and all that follows through the period at
the end and inserting ``In implementing this section, the
Secretary shall provide for the maximum appropriate
coordination with part B of the Health Care Quality
Improvement Act of 1986 (42 U.S.C. 11131 et seq.) and section
1128E.''.
(c) Conforming Amendment.--Section 1128C(a)(1) of the
Social Security Act (42 U.S.C. 1320a-7c(a)(1)) is amended--
(1) in subparagraph (C), by adding ``and'' after the comma
at the end;
(2) in subparagraph (D), by striking ``, and'' and
inserting a period; and
(3) by striking subparagraph (E).
(d) Transition Process; Effective Date.--
(1) In general.--Effective on the date of enactment of this
Act, the Secretary of Health and Human Services (in this
section referred to as the ``Secretary'') shall implement a
transition process under which, by not later than the end of
the transition period described in paragraph (5), the
Secretary shall cease operating the Healthcare Integrity and
Protection Data Bank established under section 1128E of the
Social Security Act (as in effect before the effective date
specified in paragraph (6)) and shall transfer all data
collected in the Healthcare Integrity and Protection Data
Bank to the National Practitioner Data Bank established
pursuant to the Health Care Quality Improvement Act of 1986
(42 U.S.C. 11101 et seq.). During such transition process,
the Secretary shall have in effect appropriate procedures to
ensure that data collection and access to the Healthcare
Integrity and Protection Data Bank and the National
Practitioner Data Bank are not disrupted.
(2) Regulations.--The Secretary shall promulgate
regulations to carry out the amendments made by subsections
(a) and (b).
(3) Funding.--
(A) Availability of fees.--Fees collected pursuant to
section 1128E(d)(2) of the Social Security Act prior to the
effective date specified in paragraph (6) for the disclosure
of information in the Healthcare Integrity and Protection
Data Bank shall be available to the Secretary, without fiscal
year limitation, for payment of costs related to the
transition process described in paragraph (1). Any such fees
remaining after the transition period is complete shall be
available to the Secretary, without fiscal year limitation,
for payment of the costs of operating the National
Practitioner Data Bank.
(B) Availability of additional funds.--In addition to the
fees described in subparagraph (A), any funds available to
the Secretary or to the Inspector General of the Department
of Health and Human Services for a purpose related to
combating health care fraud, waste, or abuse shall be
available to the extent necessary for operating the
Healthcare Integrity and Protection Data Bank during the
transition period, including systems testing and other
activities necessary to ensure that information formerly
reported to the Healthcare Integrity and Protection Data Bank
will be accessible through the National Practitioner Data
Bank after the end of such transition period.
[[Page H2087]]
(4) Special provision for access to the national
practitioner data bank by the department of veterans
affairs.--
(A) In general.--Notwithstanding any other provision of
law, during the 1-year period that begins on the effective
date specified in paragraph (6), the information described in
subparagraph (B) shall be available from the National
Practitioner Data Bank to the Secretary of Veterans Affairs
without charge.
(B) Information described.--For purposes of subparagraph
(A), the information described in this subparagraph is the
information that would, but for the amendments made by this
section, have been available to the Secretary of Veterans
Affairs from the Healthcare Integrity and Protection Data
Bank.
(5) Transition period defined.--For purposes of this
subsection, the term ``transition period'' means the period
that begins on the date of enactment of this Act and ends on
the later of--
(A) the date that is 1 year after such date of enactment;
or
(B) the effective date of the regulations promulgated under
paragraph (2).
(6) Effective date.--The amendments made by subsections
(a), (b), and (c) shall take effect on the first day after
the final day of the transition period.
SEC. 6404. MAXIMUM PERIOD FOR SUBMISSION OF MEDICARE CLAIMS
REDUCED TO NOT MORE THAN 12 MONTHS.
(a) Reducing Maximum Period for Submission.--
(1) Part a.--Section 1814(a) of the Social Security Act (42
U.S.C. 1395f(a)(1)) is amended--
(A) in paragraph (1), by striking ``period of 3 calendar
years'' and all that follows through the semicolon and
inserting ``period ending 1 calendar year after the date of
service;''; and
(B) by adding at the end the following new sentence: ``In
applying paragraph (1), the Secretary may specify exceptions
to the 1 calendar year period specified in such paragraph.''
(2) Part b.--
(A) Section 1842(b)(3) of such Act (42 U.S.C.
1395u(b)(3)(B)) is amended--
(i) in subparagraph (B), in the flush language following
clause (ii), by striking ``close of the calendar year
following the year in which such service is furnished
(deeming any service furnished in the last 3 months of any
calendar year to have been furnished in the succeeding
calendar year)'' and inserting ``period ending 1 calendar
year after the date of service''; and
(ii) by adding at the end the following new sentence: ``In
applying subparagraph (B), the Secretary may specify
exceptions to the 1 calendar year period specified in such
subparagraph.''
(B) Section 1835(a) of such Act (42 U.S.C. 1395n(a)) is
amended--
(i) in paragraph (1), by striking ``period of 3 calendar
years'' and all that follows through the semicolon and
inserting ``period ending 1 calendar year after the date of
service;''; and
(ii) by adding at the end the following new sentence: ``In
applying paragraph (1), the Secretary may specify exceptions
to the 1 calendar year period specified in such paragraph.''
(b) Effective Date.--
(1) In general.--The amendments made by subsection (a)
shall apply to services furnished on or after January 1,
2010.
(2) Services furnished before 2010.--In the case of
services furnished before January 1, 2010, a bill or request
for payment under section 1814(a)(1), 1842(b)(3)(B), or
1835(a) shall be filed not later that December 31, 2010.
SEC. 6405. PHYSICIANS WHO ORDER ITEMS OR SERVICES REQUIRED TO
BE MEDICARE ENROLLED PHYSICIANS OR ELIGIBLE
PROFESSIONALS.
(a) DME.--Section 1834(a)(11)(B) of the Social Security Act
(42 U.S.C. 1395m(a)(11)(B)) is amended by striking
``physician'' and inserting ``physician enrolled under
section 1866(j) or an eligible professional under section
1848(k)(3)(B) that is enrolled under section 1866(j)''.
(b) Home Health Services.--
(1) Part a.--Section 1814(a)(2) of such Act (42 U.S.C.
1395(a)(2)) is amended in the matter preceding subparagraph
(A) by inserting ``in the case of services described in
subparagraph (C), a physician enrolled under section 1866(j)
or an eligible professional under section 1848(k)(3)(B),''
before ``or, in the case of services''.
(2) Part b.--Section 1835(a)(2) of such Act (42 U.S.C.
1395n(a)(2)) is amended in the matter preceding subparagraph
(A) by inserting ``, or in the case of services described in
subparagraph (A), a physician enrolled under section 1866(j)
or an eligible professional under section 1848(k)(3)(B),''
after ``a physician''.
(c) Application to Other Items or Services.--The Secretary
may extend the requirement applied by the amendments made by
subsections (a) and (b) to durable medical equipment and home
health services (relating to requiring certifications and
written orders to be made by enrolled physicians and health
professions) to all other categories of items or services
under title XVIII of the Social Security Act (42 U.S.C. 1395
et seq.), including covered part D drugs as defined in
section 1860D-2(e) of such Act (42 U.S.C. 1395w-102), that
are ordered, prescribed, or referred by a physician enrolled
under section 1866(j) of such Act (42 U.S.C. 1395cc(j)) or an
eligible professional under section 1848(k)(3)(B) of such Act
(42 U.S.C. 1395w-4(k)(3)(B)).
(d) Effective Date.--The amendments made by this section
shall apply to written orders and certifications made on or
after July 1, 2010.
SEC. 6406. REQUIREMENT FOR PHYSICIANS TO PROVIDE
DOCUMENTATION ON REFERRALS TO PROGRAMS AT HIGH
RISK OF WASTE AND ABUSE.
(a) Physicians and Other Suppliers.--Section 1842(h) of the
Social Security Act (42 U.S.C. 1395u(h)) is amended by adding
at the end the following new paragraph:
``(9) The Secretary may revoke enrollment, for a period of
not more than one year for each act, for a physician or
supplier under section 1866(j) if such physician or supplier
fails to maintain and, upon request of the Secretary, provide
access to documentation relating to written orders or
requests for payment for durable medical equipment,
certifications for home health services, or referrals for
other items or services written or ordered by such physician
or supplier under this title, as specified by the
Secretary.''.
(b) Providers of Services.--Section 1866(a)(1) of such Act
(42 U.S.C. 1395cc) is further amended--
(1) in subparagraph (U), by striking at the end ``and'';
(2) in subparagraph (V), by striking the period at the end
and adding ``; and''; and
(3) by adding at the end the following new subparagraph:
``(W) maintain and, upon request of the Secretary, provide
access to documentation relating to written orders or
requests for payment for durable medical equipment,
certifications for home health services, or referrals for
other items or services written or ordered by the provider
under this title, as specified by the Secretary.''.
(c) OIG Permissive Exclusion Authority.--Section
1128(b)(11) of the Social Security Act (42 U.S.C. 1320a-
7(b)(11)) is amended by inserting ``, ordering, referring for
furnishing, or certifying the need for'' after
``furnishing''.
(d) Effective Date.--The amendments made by this section
shall apply to orders, certifications, and referrals made on
or after January 1, 2010.
SEC. 6407. FACE TO FACE ENCOUNTER WITH PATIENT REQUIRED
BEFORE PHYSICIANS MAY CERTIFY ELIGIBILITY FOR
HOME HEALTH SERVICES OR DURABLE MEDICAL
EQUIPMENT UNDER MEDICARE.
(a) Condition of Payment for Home Health Services.--
(1) Part a.--Section 1814(a)(2)(C) of such Act is amended--
(A) by striking ``and such services'' and inserting ``such
services''; and
(B) by inserting after ``care of a physician'' the
following: ``, and, in the case of a certification made by a
physician after January 1, 2010, prior to making such
certification the physician must document that the physician
himself or herself has had a face-to-face encounter
(including through use of telehealth, subject to the
requirements in section 1834(m), and other than with respect
to encounters that are incident to services involved) with
the individual within a reasonable timeframe as determined by
the Secretary''.
(2) Part b.--Section 1835(a)(2)(A) of the Social Security
Act is amended--
(A) by striking ``and'' before ``(iii)''; and
(B) by inserting after ``care of a physician'' the
following: ``, and (iv) in the case of a certification after
January 1, 2010, prior to making such certification the
physician must document that the physician has had a face-to-
face encounter (including through use of telehealth and other
than with respect to encounters that are incident to services
involved) with the individual during the 6-month period
preceding such certification, or other reasonable timeframe
as determined by the Secretary''.
(b) Condition of Payment for Durable Medical Equipment.--
Section 1834(a)(11)(B) of the Social Security Act (42 U.S.C.
1395m(a)(11)(B)) is amended--
(1) by striking ``Order.--The Secretary'' and inserting
``Order.--
``(i) In general.--The Secretary''; and
(2) by adding at the end the following new clause:
``(ii) Requirement for face to face encounter.--The
Secretary shall require that such an order be written
pursuant to the physician documenting that a physician, a
physician assistant, a nurse practitioner, or a clinical
nurse specialist (as those terms are defined in section
1861(aa)(5)) has had a face-to-face encounter (including
through use of telehealth under subsection (m) and other than
with respect to encounters that are incident to services
involved) with the individual involved during the 6-month
period preceding such written order, or other reasonable
timeframe as determined by the Secretary.''.
(c) Application to Other Areas Under Medicare.--The
Secretary may apply the face-to-face encounter requirement
described in the amendments made by subsections (a) and (b)
to other items and services for which payment is provided
under title XVIII of the Social Security Act based upon a
finding that such an decision would reduce the risk of waste,
fraud, or abuse.
(d) Application to Medicaid.--The requirements pursuant to
the amendments made by subsections (a) and (b) shall apply in
the case of physicians making certifications for home health
services under title XIX of the Social Security Act in the
same manner and to the same extent as such requirements apply
in the case of physicians making such certifications under
title XVIII of such Act.
SEC. 6408. ENHANCED PENALTIES.
(a) Civil Monetary Penalties for False Statements or
Delaying Inspections.--Section 1128A(a) of the Social
Security Act (42 U.S.C. 1320a-7a(a)), as amended by section
5002(d)(2)(A), is amended--
(1) in paragraph (6), by striking ``or'' at the end; and
(2) by inserting after paragraph (7) the following new
paragraphs:
``(8) knowingly makes, uses, or causes to be made or used,
a false record or statement material to a false or fraudulent
claim for payment for items and services furnished under a
Federal health care program; or
``(9) fails to grant timely access, upon reasonable request
(as defined by the Secretary in regulations), to the
Inspector General of the Department of Health and Human
Services, for the
[[Page H2088]]
purpose of audits, investigations, evaluations, or other
statutory functions of the Inspector General of the
Department of Health and Human Services;''; and
(3) in the first sentence--
(A) by striking ``or in cases under paragraph (7)'' and
inserting ``in cases under paragraph (7)''; and
(B) by striking ``act)'' and inserting ``act, in cases
under paragraph (8), $50,000 for each false record or
statement, or in cases under paragraph (9), $15,000 for each
day of the failure described in such paragraph)''.
(b) Medicare Advantage and Part D Plans.--
(1) Ensuring timely inspections relating to contracts with
ma organizations.--Section 1857(d)(2) of such Act (42 U.S.C.
1395w-27(d)(2)) is amended--
(A) in subparagraph (A), by inserting ``timely'' before
``inspect''; and
(B) in subparagraph (B), by inserting ``timely'' before
``audit and inspect''.
(2) Marketing violations.--Section 1857(g)(1) of the Social
Security Act (42 U.S.C. 1395w-27(g)(1)) is amended--
(A) in subparagraph (F), by striking ``or'' at the end;
(B) by inserting after subparagraph (G) the following new
subparagraphs:
``(H) except as provided under subparagraph (C) or (D) of
section 1860D-1(b)(1), enrolls an individual in any plan
under this part without the prior consent of the individual
or the designee of the individual;
``(I) transfers an individual enrolled under this part from
one plan to another without the prior consent of the
individual or the designee of the individual or solely for
the purpose of earning a commission;
``(J) fails to comply with marketing restrictions described
in subsections (h) and (j) of section 1851 or applicable
implementing regulations or guidance; or
``(K) employs or contracts with any individual or entity
who engages in the conduct described in subparagraphs (A)
through (J) of this paragraph;''; and
(C) by adding at the end the following new sentence: ``The
Secretary may provide, in addition to any other remedies
authorized by law, for any of the remedies described in
paragraph (2), if the Secretary determines that any employee
or agent of such organization, or any provider or supplier
who contracts with such organization, has engaged in any
conduct described in subparagraphs (A) through (K) of this
paragraph.''.
(3) Provision of false information.--Section 1857(g)(2)(A)
of the Social Security Act (42 U.S.C. 1395w-27(g)(2)(A)) is
amended by inserting ``except with respect to a determination
under subparagraph (E), an assessment of not more than the
amount claimed by such plan or plan sponsor based upon the
misrepresentation or falsified information involved,'' after
``for each such determination,''.
(c) Obstruction of Program Audits.--Section 1128(b)(2) of
the Social Security Act (42 U.S.C. 1320a-7(b)(2)) is
amended--
(1) in the heading, by inserting ``or audit'' after
``investigation''; and
(2) by striking ``investigation into'' and all that follows
through the period and inserting ``investigation or audit
related to--''
``(i) any offense described in paragraph (1) or in
subsection (a); or
``(ii) the use of funds received, directly or indirectly,
from any Federal health care program (as defined in section
1128B(f)).''.
(d) Effective Date.--
(1) In general.--Except as provided in paragraph (2), the
amendments made by this section shall apply to acts committed
on or after January 1, 2010.
(2) Exception.--The amendments made by subsection (b)(1)
take effect on the date of enactment of this Act.
SEC. 6409. MEDICARE SELF-REFERRAL DISCLOSURE PROTOCOL.
(a) Development of Self-Referral Disclosure Protocol.--
(1) In general.--The Secretary of Health and Human
Services, in cooperation with the Inspector General of the
Department of Health and Human Services, shall establish, not
later than 6 months after the date of the enactment of this
Act, a protocol to enable health care providers of services
and suppliers to disclose an actual or potential violation of
section 1877 of the Social Security Act (42 U.S.C. 1395nn)
pursuant to a self-referral disclosure protocol (in this
section referred to as an ``SRDP''). The SRDP shall include
direction to health care providers of services and suppliers
on--
(A) a specific person, official, or office to whom such
disclosures shall be made; and
(B) instruction on the implication of the SRDP on corporate
integrity agreements and corporate compliance agreements.
(2) Publication on internet website of srdp information.--
The Secretary of Health and Human Services shall post
information on the public Internet website of the Centers for
Medicare & Medicaid Services to inform relevant stakeholders
of how to disclose actual or potential violations pursuant to
an SRDP.
(3) Relation to advisory opinions.--The SRDP shall be
separate from the advisory opinion process set forth in
regulations implementing section 1877(g) of the Social
Security Act.
(b) Reduction in Amounts Owed.--The Secretary of Health and
Human Services is authorized to reduce the amount due and
owing for all violations under section 1877 of the Social
Security Act to an amount less than that specified in
subsection (g) of such section. In establishing such amount
for a violation, the Secretary may consider the following
factors:
(1) The nature and extent of the improper or illegal
practice.
(2) The timeliness of such self-disclosure.
(3) The cooperation in providing additional information
related to the disclosure.
(4) Such other factors as the Secretary considers
appropriate.
(c) Report.--Not later than 18 months after the date on
which the SRDP protocol is established under subsection
(a)(1), the Secretary shall submit to Congress a report on
the implementation of this section. Such report shall
include--
(1) the number of health care providers of services and
suppliers making disclosures pursuant to the SRDP;
(2) the amounts collected pursuant to the SRDP;
(3) the types of violations reported under the SRDP; and
(4) such other information as may be necessary to evaluate
the impact of this section.
SEC. 6410. ADJUSTMENTS TO THE MEDICARE DURABLE MEDICAL
EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES
COMPETITIVE ACQUISITION PROGRAM.
(a) Expansion of Round 2 of the DME Competitive Bidding
Program.--Section 1847(a)(1) of the Social Security Act (42
U.S.C. 1395w-3(a)(1)) is amended--
(1) in subparagraph (B)(i)(II), by striking ``70'' and
inserting ``91''; and
(2) in subparagraph (D)(ii)--
(A) in subclause (I), by striking ``and'' at the end;
(B) by redesignating subclause (II) as subclause (III); and
(C) by inserting after subclause (I) the following new
subclause:
``(II) the Secretary shall include the next 21 largest
metropolitan statistical areas by total population (after
those selected under subclause (I)) for such round; and''.
(b) Requirement to Either Competitively Bid Areas or Use
Competitive Bid Prices by 2016.--Section 1834(a)(1)(F) of the
Social Security Act (42 U.S.C. 1395m(a)(1)(F)) is amended--
(1) in clause (i), by striking ``and'' at the end;
(2) in clause (ii)--
(A) by inserting ``(and, in the case of covered items
furnished on or after January 1, 2016, subject to clause
(iii), shall)'' after ``may''; and
(B) by striking the period at the end and inserting ``;
and''; and
(3) by adding at the end the following new clause:
``(iii) in the case of covered items furnished on or after
January 1, 2016, the Secretary shall continue to make such
adjustments described in clause (ii) as, under such
competitive acquisition programs, additional covered items
are phased in or information is updated as contracts under
section 1847 are recompeted in accordance with section
1847(b)(3)(B).''.
SEC. 6411. EXPANSION OF THE RECOVERY AUDIT CONTRACTOR (RAC)
PROGRAM.
(a) Expansion to Medicaid.--
(1) State plan amendment.--Section 1902(a)(42) of the
Social Security Act (42 U.S.C. 1396a(a)(42)) is amended--
(A) by striking ``that the records'' and inserting ``that--
``(A) the records'';
(B) by inserting ``and'' after the semicolon; and
(C) by adding at the end the following:
``(B) not later than December 31, 2010, the State shall--
``(i) establish a program under which the State contracts
(consistent with State law and in the same manner as the
Secretary enters into contracts with recovery audit
contractors under section 1893(h), subject to such exceptions
or requirements as the Secretary may require for purposes of
this title or a particular State) with 1 or more recovery
audit contractors for the purpose of identifying
underpayments and overpayments and recouping overpayments
under the State plan and under any waiver of the State plan
with respect to all services for which payment is made to any
entity under such plan or waiver; and
``(ii) provide assurances satisfactory to the Secretary
that--
``(I) under such contracts, payment shall be made to such a
contractor only from amounts recovered;
``(II) from such amounts recovered, payment--
``(aa) shall be made on a contingent basis for collecting
overpayments; and
``(bb) may be made in such amounts as the State may specify
for identifying underpayments;
``(III) the State has an adequate process for entities to
appeal any adverse determination made by such contractors;
and
``(IV) such program is carried out in accordance with such
requirements as the Secretary shall specify, including--
``(aa) for purposes of section 1903(a)(7), that amounts
expended by the State to carry out the program shall be
considered amounts expended as necessary for the proper and
efficient administration of the State plan or a waiver of the
plan;
``(bb) that section 1903(d) shall apply to amounts
recovered under the program; and
``(cc) that the State and any such contractors under
contract with the State shall coordinate such recovery audit
efforts with other contractors or entities performing audits
of entities receiving payments under the State plan or waiver
in the State, including efforts with Federal and State law
enforcement with respect to the Department of Justice,
including the Federal Bureau of Investigations, the Inspector
General of the Department of Health and Human Services, and
the State medicaid fraud control unit; and''.
(2) Coordination; regulations.--
(A) In general.--The Secretary of Health and Human
Services, acting through the Administrator of the Centers for
Medicare & Medicaid Services, shall coordinate the expansion
of the Recovery Audit Contractor program to Medicaid
[[Page H2089]]
with States, particularly with respect to each State that
enters into a contract with a recovery audit contractor for
purposes of the State's Medicaid program prior to December
31, 2010.
(B) Regulations.--The Secretary of Health and Human
Services shall promulgate regulations to carry out this
subsection and the amendments made by this subsection,
including with respect to conditions of Federal financial
participation, as specified by the Secretary.
(b) Expansion to Medicare Parts C and D.--Section 1893(h)
of the Social Security Act (42 U.S.C. 1395ddd(h)) is
amended--
(1) in paragraph (1), in the matter preceding subparagraph
(A), by striking ``part A or B'' and inserting ``this
title'';
(2) in paragraph (2), by striking ``parts A and B'' and
inserting ``this title'';
(3) in paragraph (3), by inserting ``(not later than
December 31, 2010, in the case of contracts relating to
payments made under part C or D)'' after ``2010'';
(4) in paragraph (4), in the matter preceding subparagraph
(A), by striking ``part A or B'' and inserting ``this
title''; and
(5) by adding at the end the following:
``(9) Special rules relating to parts c and d.--The
Secretary shall enter into contracts under paragraph (1) to
require recovery audit contractors to--
``(A) ensure that each MA plan under part C has an anti-
fraud plan in effect and to review the effectiveness of each
such anti-fraud plan;
``(B) ensure that each prescription drug plan under part D
has an anti-fraud plan in effect and to review the
effectiveness of each such anti-fraud plan;
``(C) examine claims for reinsurance payments under section
1860D-15(b) to determine whether prescription drug plans
submitting such claims incurred costs in excess of the
allowable reinsurance costs permitted under paragraph (2) of
that section; and
``(D) review estimates submitted by prescription drug plans
by private plans with respect to the enrollment of high cost
beneficiaries (as defined by the Secretary) and to compare
such estimates with the numbers of such beneficiaries
actually enrolled by such plans.''.
(c) Annual Report.--The Secretary of Health and Human
Services, acting through the Administrator of the Centers for
Medicare & Medicaid Services, shall submit an annual report
to Congress concerning the effectiveness of the Recovery
Audit Contractor program under Medicaid and Medicare and
shall include such reports recommendations for expanding or
improving the program.
Subtitle F--Additional Medicaid Program Integrity Provisions
SEC. 6501. TERMINATION OF PROVIDER PARTICIPATION UNDER
MEDICAID IF TERMINATED UNDER MEDICARE OR OTHER
STATE PLAN.
Section 1902(a)(39) of the Social Security Act (42 U.S.C.
42 U.S.C. 1396a(a)) is amended by inserting after ``1128A,''
the following: ``terminate the participation of any
individual or entity in such program if (subject to such
exceptions as are permitted with respect to exclusion under
sections 1128(c)(3)(B) and 1128(d)(3)(B)) participation of
such individual or entity is terminated under title XVIII or
any other State plan under this title,''.
SEC. 6502. MEDICAID EXCLUSION FROM PARTICIPATION RELATING TO
CERTAIN OWNERSHIP, CONTROL, AND MANAGEMENT
AFFILIATIONS.
Section 1902(a) of the Social Security Act (42 U.S.C.
1396a(a)), as amended by section 6401(b), is amended by
inserting after paragraph (77) the following:
``(78) provide that the State agency described in paragraph
(9) exclude, with respect to a period, any individual or
entity from participation in the program under the State plan
if such individual or entity owns, controls, or manages an
entity that (or if such entity is owned, controlled, or
managed by an individual or entity that)--
``(A) has unpaid overpayments (as defined by the Secretary)
under this title during such period determined by the
Secretary or the State agency to be delinquent;
``(B) is suspended or excluded from participation under or
whose participation is terminated under this title during
such period; or
``(C) is affiliated with an individual or entity that has
been suspended or excluded from participation under this
title or whose participation is terminated under this title
during such period;''.
SEC. 6503. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE
PAYEES REQUIRED TO REGISTER UNDER MEDICAID.
(a) In General.--Section 1902(a) of the Social Security Act
(42 U.S.C. 42 U.S.C. 1396a(a)), as amended by section
6502(a), is amended by inserting after paragraph (78), the
following:
``(79) provide that any agent, clearinghouse, or other
alternate payee (as defined by the Secretary) that submits
claims on behalf of a health care provider must register with
the State and the Secretary in a form and manner specified by
the Secretary;''.
SEC. 6504. REQUIREMENT TO REPORT EXPANDED SET OF DATA
ELEMENTS UNDER MMIS TO DETECT FRAUD AND ABUSE.
(a) In General.--Section 1903(r)(1)(F) of the Social
Security Act (42 U.S.C. 1396b(r)(1)(F)) is amended by
inserting after ``necessary'' the following: ``and including,
for data submitted to the Secretary on or after January 1,
2010, data elements from the automated data system that the
Secretary determines to be necessary for program integrity,
program oversight, and administration, at such frequency as
the Secretary shall determine''.
(b) Managed Care Organizations.--
(1) In general.--Section 1903(m)(2)(A)(xi) of the Social
Security Act (42 U.S.C. 1396b(m)(2)(A)(xi)) is amended by
inserting ``and for the provision of such data to the State
at a frequency and level of detail to be specified by the
Secretary'' after ``patients''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply with respect to contract years beginning on or
after January 1, 2010.
SEC. 6505. PROHIBITION ON PAYMENTS TO INSTITUTIONS OR
ENTITIES LOCATED OUTSIDE OF THE UNITED STATES.
Section 1902(a) of the Social Security Act (42 U.S.C.
1396b(a)), as amended by section 6503, is amended by
inserting after paragraph (79) the following new paragraph:
``(80) provide that the State shall not provide any
payments for items or services provided under the State plan
or under a waiver to any financial institution or entity
located outside of the United States;''.
SEC. 6506. OVERPAYMENTS.
(a) Extension of Period for Collection of Overpayments Due
to Fraud.--
(1) In general.--Section 1903(d)(2) of the Social Security
Act (42 U.S.C. 1396b(d)(2)) is amended--
(A) in subparagraph (C)--
(i) in the first sentence, by striking ``60 days'' and
inserting ``1 year''; and
(ii) in the second sentence, by striking ``60 days'' and
inserting ``1-year period''; and
(B) in subparagraph (D)--
(i) in inserting ``(i)'' after ``(D)''; and
(ii) by adding at the end the following:
``(ii) In any case where the State is unable to recover a
debt which represents an overpayment (or any portion thereof)
made to a person or other entity due to fraud within 1 year
of discovery because there is not a final determination of
the amount of the overpayment under an administrative or
judicial process (as applicable), including as a result of a
judgment being under appeal, no adjustment shall be made in
the Federal payment to such State on account of such
overpayment (or portion thereof) before the date that is 30
days after the date on which a final judgment (including, if
applicable, a final determination on an appeal) is made.''.
(2) Effective date.--The amendments made by this subsection
take effect on the date of enactment of this Act and apply to
overpayments discovered on or after that date.
(b) Corrective Action.--The Secretary shall promulgate
regulations that require States to correct Federally
identified claims overpayments, of an ongoing or recurring
nature, with new Medicaid Management Information System
(MMIS) edits, audits, or other appropriate corrective action.
SEC. 6507. MANDATORY STATE USE OF NATIONAL CORRECT CODING
INITIATIVE.
Section 1903(r) of the Social Security Act (42 U.S.C.
1396b(r)) is amended--
(1) in paragraph (1)(B)--
(A) in clause (ii), by striking ``and'' at the end;
(B) in clause (iii), by adding ``and'' after the semi-
colon; and
(C) by adding at the end the following new clause:
``(iv) effective for claims filed on or after October 1,
2010, incorporate compatible methodologies of the National
Correct Coding Initiative administered by the Secretary (or
any successor initiative to promote correct coding and to
control improper coding leading to inappropriate payment) and
such other methodologies of that Initiative (or such other
national correct coding methodologies) as the Secretary
identifies in accordance with paragraph (4);''; and
(2) by adding at the end the following new paragraph:
``(4) For purposes of paragraph (1)(B)(iv), the Secretary
shall do the following:
``(A) Not later than September 1, 2010:
``(i) Identify those methodologies of the National Correct
Coding Initiative administered by the Secretary (or any
successor initiative to promote correct coding and to control
improper coding leading to inappropriate payment) which are
compatible to claims filed under this title.
``(ii) Identify those methodologies of such Initiative (or
such other national correct coding methodologies) that should
be incorporated into claims filed under this title with
respect to items or services for which States provide medical
assistance under this title and no national correct coding
methodologies have been established under such Initiative
with respect to title XVIII.
``(iii) Notify States of--
``(I) the methodologies identified under subparagraphs (A)
and (B) (and of any other national correct coding
methodologies identified under subparagraph (B)); and
``(II) how States are to incorporate such methodologies
into claims filed under this title.
``(B) Not later than March 1, 2011, submit a report to
Congress that includes the notice to States under clause
(iii) of subparagraph (A) and an analysis supporting the
identification of the methodologies made under clauses (i)
and (ii) of subparagraph (A).''.
SEC. 6508. GENERAL EFFECTIVE DATE.
(a) In General.--Except as otherwise provided in this
subtitle, this subtitle and the amendments made by this
subtitle take effect on January 1, 2011, without regard to
whether final regulations to carry out such amendments and
subtitle have been promulgated by that date.
(b) Delay if State Legislation Required.--In the case of a
State plan for medical assistance under title XIX of the
Social Security Act or a child health plan under title XXI of
such Act which the Secretary of Health and Human Services
determines requires State legislation (other than legislation
appropriating funds) in order for the plan to meet the
additional requirement imposed by the amendments made by this
subtitle, the State plan or child health plan shall not be
regarded as failing to comply with
[[Page H2090]]
the requirements of such title solely on the basis of its
failure to meet this additional requirement before the first
day of the first calendar quarter beginning after the close
of the first regular session of the State legislature that
begins after the date of the enactment of this Act. For
purposes of the previous sentence, in the case of a State
that has a 2-year legislative session, each year of such
session shall be deemed to be a separate regular session of
the State legislature.
Subtitle G--Additional Program Integrity Provisions
SEC. 6601. PROHIBITION ON FALSE STATEMENTS AND
REPRESENTATIONS.
(a) Prohibition.--Part 5 of subtitle B of title I of the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
1131 et seq.) is amended by adding at the end the following:
``SEC. 519. PROHIBITION ON FALSE STATEMENTS AND
REPRESENTATIONS.
``No person, in connection with a plan or other arrangement
that is multiple employer welfare arrangement described in
section 3(40), shall make a false statement or false
representation of fact, knowing it to be false, in connection
with the marketing or sale of such plan or arrangement, to
any employee, any member of an employee organization, any
beneficiary, any employer, any employee organization, the
Secretary, or any State, or the representative or agent of
any such person, State, or the Secretary, concerning--
``(1) the financial condition or solvency of such plan or
arrangement;
``(2) the benefits provided by such plan or arrangement;
``(3) the regulatory status of such plan or other
arrangement under any Federal or State law governing
collective bargaining, labor management relations, or intern
union affairs; or
``(4) the regulatory status of such plan or other
arrangement regarding exemption from state regulatory
authority under this Act.
This section shall not apply to any plan or arrangement that
does not fall within the meaning of the term `multiple
employer welfare arrangement' under section 3(40)(A).''.
(b) Criminal Penalties.--Section 501 of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1131) is
amended--
(1) by inserting ``(a)'' before ``Any person''; and
(2) by adding at the end the following:
``(b) Any person that violates section 519 shall upon
conviction be imprisoned not more than 10 years or fined
under title 18, United States Code, or both.''.
(c) Conforming Amendment.--The table of sections for part 5
of subtitle B of title I of the Employee Retirement Income
Security Act of 1974 is amended by adding at the end the
following:
``Sec. 519. Prohibition on false statement and representations.''.
SEC. 6602. CLARIFYING DEFINITION.
Section 24(a)(2) of title 18, United States Code, is
amended by inserting ``or section 411, 518, or 511 of the
Employee Retirement Income Security Act of 1974,'' after
``1954 of this title''.
SEC. 6603. DEVELOPMENT OF MODEL UNIFORM REPORT FORM.
Part C of title XXVII of the Public Health Service Act (42
U.S.C. 300gg-91 et seq.) is amended by adding at the end the
following:
``SEC. 2794. UNIFORM FRAUD AND ABUSE REFERRAL FORMAT.
``The Secretary shall request the National Association of
Insurance Commissioners to develop a model uniform report
form for private health insurance issuer seeking to refer
suspected fraud and abuse to State insurance departments or
other responsible State agencies for investigation. The
Secretary shall request that the National Association of
Insurance Commissioners develop recommendations for uniform
reporting standards for such referrals.''.
SEC. 6604. APPLICABILITY OF STATE LAW TO COMBAT FRAUD AND
ABUSE.
(a) In General.--Part 5 of subtitle B of title I of the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
1131 et seq.), as amended by section 6601, is further amended
by adding at the end the following:
``SEC. 520. APPLICABILITY OF STATE LAW TO COMBAT FRAUD AND
ABUSE.
``The Secretary may, for the purpose of identifying,
preventing, or prosecuting fraud and abuse, adopt regulatory
standards establishing, or issue an order relating to a
specific person establishing, that a person engaged in the
business of providing insurance through a multiple employer
welfare arrangement described in section 3(40) is subject to
the laws of the States in which such person operates which
regulate insurance in such State, notwithstanding section
514(b)(6) of this Act or the Liability Risk Retention Act of
1986, and regardless of whether the law of the State is
otherwise preempted under any of such provisions. This
section shall not apply to any plan or arrangement that does
not fall within the meaning of the term `multiple employer
welfare arrangement' under section 3(40)(A).''.
(b) Conforming Amendment.--The table of sections for part 5
of subtitle B of title I of the Employee Retirement Income
Security Act of 1974, as amended by section 6601, is further
amended by adding at the end the following:
``Sec. 520. Applicability of State law to combat fraud and abuse.''.
SEC. 6605. ENABLING THE DEPARTMENT OF LABOR TO ISSUE
ADMINISTRATIVE SUMMARY CEASE AND DESIST ORDERS
AND SUMMARY SEIZURES ORDERS AGAINST PLANS THAT
ARE IN FINANCIALLY HAZARDOUS CONDITION.
(a) In General.--Part 5 of subtitle B of title I of the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
1131 et seq.), as amended by section 6604, is further amended
by adding at the end the following:
``SEC. 521. ADMINISTRATIVE SUMMARY CEASE AND DESIST ORDERS
AND SUMMARY SEIZURE ORDERS AGAINST MULTIPLE
EMPLOYER WELFARE ARRANGEMENTS IN FINANCIALLY
HAZARDOUS CONDITION.
``(a) In General.--The Secretary may issue a cease and
desist (ex parte) order under this title if it appears to the
Secretary that the alleged conduct of a multiple employer
welfare arrangement described in section 3(40), other than a
plan or arrangement described in subsection (g), is
fraudulent, or creates an immediate danger to the public
safety or welfare, or is causing or can be reasonably
expected to cause significant, imminent, and irreparable
public injury.
``(b) Hearing.--A person that is adversely affected by the
issuance of a cease and desist order under subsection (a) may
request a hearing by the Secretary regarding such order. The
Secretary may require that a proceeding under this section,
including all related information and evidence, be conducted
in a confidential manner.
``(c) Burden of Proof.--The burden of proof in any hearing
conducted under subsection (b) shall be on the party
requesting the hearing to show cause why the cease and desist
order should be set aside.
``(d) Determination.--Based upon the evidence presented at
a hearing under subsection (b), the cease and desist order
involved may be affirmed, modified, or set aside by the
Secretary in whole or in part.
``(e) Seizure.--The Secretary may issue a summary seizure
order under this title if it appears that a multiple employer
welfare arrangement is in a financially hazardous condition.
``(f) Regulations.--The Secretary may promulgate such
regulations or other guidance as may be necessary or
appropriate to carry out this section.
``(g) Exception.--This section shall not apply to any plan
or arrangement that does not fall within the meaning of the
term `multiple employer welfare arrangement' under section
3(40)(A).''.
(b) Conforming Amendment.--The table of sections for part 5
of subtitle B of title I of the Employee Retirement Income
Security Act of 1974, as amended by section 6604, is further
amended by adding at the end the following:
``Sec. 521. Administrative summary cease and desist orders and summary
seizure orders against health plans in financially
hazardous condition.''.
SEC. 6606. MEWA PLAN REGISTRATION WITH DEPARTMENT OF LABOR.
Section 101(g) of the Employee Retirement Income Security
Act of 1974 (29 U.S.C. 1021(g)) is amended--
(1) by striking ``Secretary may'' and inserting ``Secretary
shall''; and
(2) by inserting ``to register with the Secretary prior to
operating in a State and may, by regulation, require such
multiple employer welfare arrangements'' after ``not group
health plans''.
SEC. 6607. PERMITTING EVIDENTIARY PRIVILEGE AND CONFIDENTIAL
COMMUNICATIONS.
Section 504 of the Employee Retirement Income Security Act
of 1974 (29 U.S.C. 1134) is amended by adding at the end the
following:
``(d) The Secretary may promulgate a regulation that
provides an evidentiary privilege for, and provides for the
confidentiality of communications between or among, any of
the following entities or their agents, consultants, or
employees:
``(1) A State insurance department.
``(2) A State attorney general.
``(3) The National Association of Insurance Commissioners.
``(4) The Department of Labor.
``(5) The Department of the Treasury.
``(6) The Department of Justice.
``(7) The Department of Health and Human Services.
``(8) Any other Federal or State authority that the
Secretary determines is appropriate for the purposes of
enforcing the provisions of this title.
``(e) The privilege established under subsection (d) shall
apply to communications related to any investigation, audit,
examination, or inquiry conducted or coordinated by any of
the agencies. A communication that is privileged under
subsection (d) shall not waive any privilege otherwise
available to the communicating agency or to any person who
provided the information that is communicated.''.
Subtitle H--Elder Justice Act
SEC. 6701. SHORT TITLE OF SUBTITLE.
This subtitle may be cited as the ``Elder Justice Act of
2009''.
SEC. 6702. DEFINITIONS.
Except as otherwise specifically provided, any term that is
defined in section 2011 of the Social Security Act (as added
by section 6703(a)) and is used in this subtitle has the
meaning given such term by such section.
SEC. 6703. ELDER JUSTICE.
(a) Elder Justice.--
(1) In general.--Title XX of the Social Security Act (42
U.S.C. 1397 et seq.) is amended--
(A) in the heading, by inserting ``AND ELDER JUSTICE''
after ``SOCIAL SERVICES'';
(B) by inserting before section 2001 the following:
``Subtitle A--Block Grants to States for Social Services'';
and
(C) by adding at the end the following:
``Subtitle B--Elder Justice
``SEC. 2011. DEFINITIONS.
``In this subtitle:
``(1) Abuse.--The term `abuse' means the knowing infliction
of physical or psychological
[[Page H2091]]
harm or the knowing deprivation of goods or services that are
necessary to meet essential needs or to avoid physical or
psychological harm.
``(2) Adult protective services.--The term `adult
protective services' means such services provided to adults
as the Secretary may specify and includes services such as--
``(A) receiving reports of adult abuse, neglect, or
exploitation;
``(B) investigating the reports described in subparagraph
(A);
``(C) case planning, monitoring, evaluation, and other case
work and services; and
``(D) providing, arranging for, or facilitating the
provision of medical, social service, economic, legal,
housing, law enforcement, or other protective, emergency, or
support services.
``(3) Caregiver.--The term `caregiver' means an individual
who has the responsibility for the care of an elder, either
voluntarily, by contract, by receipt of payment for care, or
as a result of the operation of law, and means a family
member or other individual who provides (on behalf of such
individual or of a public or private agency, organization, or
institution) compensated or uncompensated care to an elder
who needs supportive services in any setting.
``(4) Direct care.--The term `direct care' means care by an
employee or contractor who provides assistance or long-term
care services to a recipient.
``(5) Elder.--The term `elder' means an individual age 60
or older.
``(6) Elder justice.--The term `elder justice' means--
``(A) from a societal perspective, efforts to--
``(i) prevent, detect, treat, intervene in, and prosecute
elder abuse, neglect, and exploitation; and
``(ii) protect elders with diminished capacity while
maximizing their autonomy; and
``(B) from an individual perspective, the recognition of an
elder's rights, including the right to be free of abuse,
neglect, and exploitation.
``(7) Eligible entity.--The term `eligible entity' means a
State or local government agency, Indian tribe or tribal
organization, or any other public or private entity that is
engaged in and has expertise in issues relating to elder
justice or in a field necessary to promote elder justice
efforts.
``(8) Exploitation.--The term `exploitation' means the
fraudulent or otherwise illegal, unauthorized, or improper
act or process of an individual, including a caregiver or
fiduciary, that uses the resources of an elder for monetary
or personal benefit, profit, or gain, or that results in
depriving an elder of rightful access to, or use of,
benefits, resources, belongings, or assets.
``(9) Fiduciary.--The term `fiduciary'--
``(A) means a person or entity with the legal
responsibility--
``(i) to make decisions on behalf of and for the benefit of
another person; and
``(ii) to act in good faith and with fairness; and
``(B) includes a trustee, a guardian, a conservator, an
executor, an agent under a financial power of attorney or
health care power of attorney, or a representative payee.
``(10) Grant.--The term `grant' includes a contract,
cooperative agreement, or other mechanism for providing
financial assistance.
``(11) Guardianship.--The term `guardianship' means--
``(A) the process by which a State court determines that an
adult individual lacks capacity to make decisions about self-
care or property, and appoints another individual or entity
known as a guardian, as a conservator, or by a similar term,
as a surrogate decisionmaker;
``(B) the manner in which the court-appointed surrogate
decisionmaker carries out duties to the individual and the
court; or
``(C) the manner in which the court exercises oversight of
the surrogate decisionmaker.
``(12) Indian tribe.--
``(A) In general.--The term `Indian tribe' has the meaning
given such term in section 4 of the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450b).
``(B) Inclusion of pueblo and rancheria.--The term `Indian
tribe' includes any Pueblo or Rancheria.
``(13) Law enforcement.--The term `law enforcement' means
the full range of potential responders to elder abuse,
neglect, and exploitation including--
``(A) police, sheriffs, detectives, public safety officers,
and corrections personnel;
``(B) prosecutors;
``(C) medical examiners;
``(D) investigators; and
``(E) coroners.
``(14) Long-term care.--
``(A) In general.--The term `long-term care' means
supportive and health services specified by the Secretary for
individuals who need assistance because the individuals have
a loss of capacity for self-care due to illness, disability,
or vulnerability.
``(B) Loss of capacity for self-care.--For purposes of
subparagraph (A), the term `loss of capacity for self-care'
means an inability to engage in 1 or more activities of daily
living, including eating, dressing, bathing, management of
one's financial affairs, and other activities the Secretary
determines appropriate.
``(15) Long-term care facility.--The term `long-term care
facility' means a residential care provider that arranges
for, or directly provides, long-term care.
``(16) Neglect.--The term `neglect' means--
``(A) the failure of a caregiver or fiduciary to provide
the goods or services that are necessary to maintain the
health or safety of an elder; or
``(B) self-neglect.
``(17) Nursing facility.--
``(A) In general.--The term `nursing facility' has the
meaning given such term under section 1919(a).
``(B) Inclusion of skilled nursing facility.--The term
`nursing facility' includes a skilled nursing facility (as
defined in section 1819(a)).
``(18) Self-neglect.--The term `self-neglect' means an
adult's inability, due to physical or mental impairment or
diminished capacity, to perform essential self-care tasks
including--
``(A) obtaining essential food, clothing, shelter, and
medical care;
``(B) obtaining goods and services necessary to maintain
physical health, mental health, or general safety; or
``(C) managing one's own financial affairs.
``(19) Serious bodily injury.--
``(A) In general.--The term `serious bodily injury' means
an injury--
``(i) involving extreme physical pain;
``(ii) involving substantial risk of death;
``(iii) involving protracted loss or impairment of the
function of a bodily member, organ, or mental faculty; or
``(iv) requiring medical intervention such as surgery,
hospitalization, or physical rehabilitation.
``(B) Criminal sexual abuse.--Serious bodily injury shall
be considered to have occurred if the conduct causing the
injury is conduct described in section 2241 (relating to
aggravated sexual abuse) or 2242 (relating to sexual abuse)
of title 18, United States Code, or any similar offense under
State law.
``(20) Social.--The term `social', when used with respect
to a service, includes adult protective services.
``(21) State legal assistance developer.--The term `State
legal assistance developer' means an individual described in
section 731 of the Older Americans Act of 1965.
``(22) State long-term care ombudsman.--The term `State
Long-Term Care Ombudsman' means the State Long-Term Care
Ombudsman described in section 712(a)(2) of the Older
Americans Act of 1965.
``SEC. 2012. GENERAL PROVISIONS.
``(a) Protection of Privacy.--In pursuing activities under
this subtitle, the Secretary shall ensure the protection of
individual health privacy consistent with the regulations
promulgated under section 264(c) of the Health Insurance
Portability and Accountability Act of 1996 and applicable
State and local privacy regulations.
``(b) Rule of Construction.--Nothing in this subtitle shall
be construed to interfere with or abridge an elder's right to
practice his or her religion through reliance on prayer alone
for healing when this choice--
``(1) is contemporaneously expressed, either orally or in
writing, with respect to a specific illness or injury which
the elder has at the time of the decision by an elder who is
competent at the time of the decision;
``(2) is previously set forth in a living will, health care
proxy, or other advance directive document that is validly
executed and applied under State law; or
``(3) may be unambiguously deduced from the elder's life
history.
``PART I--NATIONAL COORDINATION OF ELDER JUSTICE ACTIVITIES AND
RESEARCH
``Subpart A--Elder Justice Coordinating Council and Advisory Board on
Elder Abuse, Neglect, and Exploitation
``SEC. 2021. ELDER JUSTICE COORDINATING COUNCIL.
``(a) Establishment.--There is established within the
Office of the Secretary an Elder Justice Coordinating Council
(in this section referred to as the `Council').
``(b) Membership.--
``(1) In general.--The Council shall be composed of the
following members:
``(A) The Secretary (or the Secretary's designee).
``(B) The Attorney General (or the Attorney General's
designee).
``(C) The head of each Federal department or agency or
other governmental entity identified by the Chair referred to
in subsection (d) as having responsibilities, or
administering programs, relating to elder abuse, neglect, and
exploitation.
``(2) Requirement.--Each member of the Council shall be an
officer or employee of the Federal Government.
``(c) Vacancies.--Any vacancy in the Council shall not
affect its powers, but shall be filled in the same manner as
the original appointment was made.
``(d) Chair.--The member described in subsection (b)(1)(A)
shall be Chair of the Council.
``(e) Meetings.--The Council shall meet at least 2 times
per year, as determined by the Chair.
``(f) Duties.--
``(1) In general.--The Council shall make recommendations
to the Secretary for the coordination of activities of the
Department of Health and Human Services, the Department of
Justice, and other relevant Federal, State, local, and
private agencies and entities, relating to elder abuse,
neglect, and exploitation and other crimes against elders.
``(2) Report.--Not later than the date that is 2 years
after the date of enactment of the Elder Justice Act of 2009
and every 2 years thereafter, the Council shall submit to the
Committee on Finance of the Senate and the Committee on Ways
and Means and the Committee on Energy and Commerce of the
House of Representatives a report that--
``(A) describes the activities and accomplishments of, and
challenges faced by--
``(i) the Council; and
``(ii) the entities represented on the Council; and
``(B) makes such recommendations for legislation, model
laws, or other action as the Council determines to be
appropriate.
[[Page H2092]]
``(g) Powers of the Council.--
``(1) Information from federal agencies.--Subject to the
requirements of section 2012(a), the Council may secure
directly from any Federal department or agency such
information as the Council considers necessary to carry out
this section. Upon request of the Chair of the Council, the
head of such department or agency shall furnish such
information to the Council.
``(2) Postal services.--The Council may use the United
States mails in the same manner and under the same conditions
as other departments and agencies of the Federal Government.
``(h) Travel Expenses.--The members of the Council shall
not receive compensation for the performance of services for
the Council. The members shall be allowed travel expenses,
including per diem in lieu of subsistence, at rates
authorized for employees of agencies under subchapter I of
chapter 57 of title 5, United States Code, while away from
their homes or regular places of business in the performance
of services for the Council. Notwithstanding section 1342 of
title 31, United States Code, the Secretary may accept the
voluntary and uncompensated services of the members of the
Council.
``(i) Detail of Government Employees.--Any Federal
Government employee may be detailed to the Council without
reimbursement, and such detail shall be without interruption
or loss of civil service status or privilege.
``(j) Status as Permanent Council.--Section 14 of the
Federal Advisory Committee Act (5 U.S.C. App.) shall not
apply to the Council.
``(k) Authorization of Appropriations.--There are
authorized to be appropriated such sums as are necessary to
carry out this section.
``SEC. 2022. ADVISORY BOARD ON ELDER ABUSE, NEGLECT, AND
EXPLOITATION.
``(a) Establishment.--There is established a board to be
known as the `Advisory Board on Elder Abuse, Neglect, and
Exploitation' (in this section referred to as the `Advisory
Board') to create short- and long-term multidisciplinary
strategic plans for the development of the field of elder
justice and to make recommendations to the Elder Justice
Coordinating Council established under section 2021.
``(b) Composition.--The Advisory Board shall be composed of
27 members appointed by the Secretary from among members of
the general public who are individuals with experience and
expertise in elder abuse, neglect, and exploitation
prevention, detection, treatment, intervention, or
prosecution.
``(c) Solicitation of Nominations.--The Secretary shall
publish a notice in the Federal Register soliciting
nominations for the appointment of members of the Advisory
Board under subsection (b).
``(d) Terms.--
``(1) In general.--Each member of the Advisory Board shall
be appointed for a term of 3 years, except that, of the
members first appointed--
``(A) 9 shall be appointed for a term of 3 years;
``(B) 9 shall be appointed for a term of 2 years; and
``(C) 9 shall be appointed for a term of 1 year.
``(2) Vacancies.--
``(A) In general.--Any vacancy on the Advisory Board shall
not affect its powers, but shall be filled in the same manner
as the original appointment was made.
``(B) Filling unexpired term.--An individual chosen to fill
a vacancy shall be appointed for the unexpired term of the
member replaced.
``(3) Expiration of terms.--The term of any member shall
not expire before the date on which the member's successor
takes office.
``(e) Election of Officers.--The Advisory Board shall elect
a Chair and Vice Chair from among its members. The Advisory
Board shall elect its initial Chair and Vice Chair at its
initial meeting.
``(f) Duties.--
``(1) Enhance communication on promoting quality of, and
preventing abuse, neglect, and exploitation in, long-term
care.--The Advisory Board shall develop collaborative and
innovative approaches to improve the quality of, including
preventing abuse, neglect, and exploitation in, long-term
care.
``(2) Collaborative efforts to develop consensus around the
management of certain quality-related factors.--
``(A) In general.--The Advisory Board shall establish
multidisciplinary panels to address, and develop consensus
on, subjects relating to improving the quality of long-term
care. At least 1 such panel shall address, and develop
consensus on, methods for managing resident-to-resident abuse
in long-term care.
``(B) Activities conducted.--The multidisciplinary panels
established under subparagraph (A) shall examine relevant
research and data, identify best practices with respect to
the subject of the panel, determine the best way to carry out
those best practices in a practical and feasible manner, and
determine an effective manner of distributing information on
such subject.
``(3) Report.--Not later than the date that is 18 months
after the date of enactment of the Elder Justice Act of 2009,
and annually thereafter, the Advisory Board shall prepare and
submit to the Elder Justice Coordinating Council, the
Committee on Finance of the Senate, and the Committee on Ways
and Means and the Committee on Energy and Commerce of the
House of Representatives a report containing--
``(A) information on the status of Federal, State, and
local public and private elder justice activities;
``(B) recommendations (including recommended priorities)
regarding--
``(i) elder justice programs, research, training, services,
practice, enforcement, and coordination;
``(ii) coordination between entities pursuing elder justice
efforts and those involved in related areas that may inform
or overlap with elder justice efforts, such as activities to
combat violence against women and child abuse and neglect;
and
``(iii) activities relating to adult fiduciary systems,
including guardianship and other fiduciary arrangements;
``(C) recommendations for specific modifications needed in
Federal and State laws (including regulations) or for
programs, research, and training to enhance prevention,
detection, and treatment (including diagnosis) of,
intervention in (including investigation of), and prosecution
of elder abuse, neglect, and exploitation;
``(D) recommendations on methods for the most effective
coordinated national data collection with respect to elder
justice, and elder abuse, neglect, and exploitation; and
``(E) recommendations for a multidisciplinary strategic
plan to guide the effective and efficient development of the
field of elder justice.
``(g) Powers of the Advisory Board.--
``(1) Information from federal agencies.--Subject to the
requirements of section 2012(a), the Advisory Board may
secure directly from any Federal department or agency such
information as the Advisory Board considers necessary to
carry out this section. Upon request of the Chair of the
Advisory Board, the head of such department or agency shall
furnish such information to the Advisory Board.
``(2) Sharing of data and reports.--The Advisory Board may
request from any entity pursuing elder justice activities
under the Elder Justice Act of 2009 or an amendment made by
that Act, any data, reports, or recommendations generated in
connection with such activities.
``(3) Postal services.--The Advisory Board may use the
United States mails in the same manner and under the same
conditions as other departments and agencies of the Federal
Government.
``(h) Travel Expenses.--The members of the Advisory Board
shall not receive compensation for the performance of
services for the Advisory Board. The members shall be allowed
travel expenses for up to 4 meetings per year, including per
diem in lieu of subsistence, at rates authorized for
employees of agencies under subchapter I of chapter 57 of
title 5, United States Code, while away from their homes or
regular places of business in the performance of services for
the Advisory Board. Notwithstanding section 1342 of title 31,
United States Code, the Secretary may accept the voluntary
and uncompensated services of the members of the Advisory
Board.
``(i) Detail of Government Employees.--Any Federal
Government employee may be detailed to the Advisory Board
without reimbursement, and such detail shall be without
interruption or loss of civil service status or privilege.
``(j) Status as Permanent Advisory Committee.--Section 14
of the Federal Advisory Committee Act (5 U.S.C. App.) shall
not apply to the advisory board.
``(k) Authorization of Appropriations.--There are
authorized to be appropriated such sums as are necessary to
carry out this section.
``SEC. 2023. RESEARCH PROTECTIONS.
``(a) Guidelines.--The Secretary shall promulgate
guidelines to assist researchers working in the area of elder
abuse, neglect, and exploitation, with issues relating to
human subject protections.
``(b) Definition of Legally Authorized Representative for
Application of Regulations.--For purposes of the application
of subpart A of part 46 of title 45, Code of Federal
Regulations, to research conducted under this subpart, the
term `legally authorized representative' means, unless
otherwise provided by law, the individual or judicial or
other body authorized under the applicable law to consent to
medical treatment on behalf of another person.
``SEC. 2024. AUTHORIZATION OF APPROPRIATIONS.
``There are authorized to be appropriated to carry out this
subpart--
``(1) for fiscal year 2011, $6,500,000; and
``(2) for each of fiscal years 2012 through 2014,
$7,000,000.
``Subpart B--Elder Abuse, Neglect, and Exploitation Forensic Centers
``SEC. 2031. ESTABLISHMENT AND SUPPORT OF ELDER ABUSE,
NEGLECT, AND EXPLOITATION FORENSIC CENTERS.
``(a) In General.--The Secretary, in consultation with the
Attorney General, shall make grants to eligible entities to
establish and operate stationary and mobile forensic centers,
to develop forensic expertise regarding, and provide services
relating to, elder abuse, neglect, and exploitation.
``(b) Stationary Forensic Centers.--The Secretary shall
make 4 of the grants described in subsection (a) to
institutions of higher education with demonstrated expertise
in forensics or commitment to preventing or treating elder
abuse, neglect, or exploitation, to establish and operate
stationary forensic centers.
``(c) Mobile Centers.--The Secretary shall make 6 of the
grants described in subsection (a) to appropriate entities to
establish and operate mobile forensic centers.
``(d) Authorized Activities.--
``(1) Development of forensic markers and methodologies.--
An eligible entity that receives a grant under this section
shall use funds made available through the grant to assist in
determining whether abuse, neglect, or exploitation occurred
and whether a crime was committed and to conduct research to
describe and disseminate information on--
``(A) forensic markers that indicate a case in which elder
abuse, neglect, or exploitation may have occurred; and
``(B) methodologies for determining, in such a case, when
and how health care, emergency service, social and protective
services, and legal service providers should intervene and
when the providers should report the case to law enforcement
authorities.
[[Page H2093]]
``(2) Development of forensic expertise.--An eligible
entity that receives a grant under this section shall use
funds made available through the grant to develop forensic
expertise regarding elder abuse, neglect, and exploitation in
order to provide medical and forensic evaluation, therapeutic
intervention, victim support and advocacy, case review, and
case tracking.
``(3) Collection of evidence.--The Secretary, in
coordination with the Attorney General, shall use data made
available by grant recipients under this section to develop
the capacity of geriatric health care professionals and law
enforcement to collect forensic evidence, including
collecting forensic evidence relating to a potential
determination of elder abuse, neglect, or exploitation.
``(e) Application.--To be eligible to receive a grant under
this section, an entity shall submit an application to the
Secretary at such time, in such manner, and containing such
information as the Secretary may require.
``(f) Authorization of Appropriations.--There are
authorized to be appropriated to carry out this section--
``(1) for fiscal year 2011, $4,000,000;
``(2) for fiscal year 2012, $6,000,000; and
``(3) for each of fiscal years 2013 and 2014, $8,000,000.
``PART II--PROGRAMS TO PROMOTE ELDER JUSTICE
``SEC. 2041. ENHANCEMENT OF LONG-TERM CARE.
``(a) Grants and Incentives for Long-Term Care Staffing.--
``(1) In general.--The Secretary shall carry out
activities, including activities described in paragraphs (2)
and (3), to provide incentives for individuals to train for,
seek, and maintain employment providing direct care in long-
term care.
``(2) Specific programs to enhance training, recruitment,
and retention of staff.--
``(A) Coordination with secretary of labor to recruit and
train long-term care staff.--The Secretary shall coordinate
activities under this subsection with the Secretary of Labor
in order to provide incentives for individuals to train for
and seek employment providing direct care in long-term care.
``(B) Career ladders and wage or benefit increases to
increase staffing in long-term care.--
``(i) In general.--The Secretary shall make grants to
eligible entities to carry out programs through which the
entities--
``(I) offer, to employees who provide direct care to
residents of an eligible entity or individuals receiving
community-based long-term care from an eligible entity,
continuing training and varying levels of certification,
based on observed clinical care practices and the amount of
time the employees spend providing direct care; and
``(II) provide, or make arrangements to provide, bonuses or
other increased compensation or benefits to employees who
achieve certification under such a program.
``(ii) Application.--To be eligible to receive a grant
under this subparagraph, an eligible entity shall submit an
application to the Secretary at such time, in such manner,
and containing such information as the Secretary may require
(which may include evidence of consultation with the State in
which the eligible entity is located with respect to carrying
out activities funded under the grant).
``(iii) Authority to limit number of applicants.--Nothing
in this subparagraph shall be construed as prohibiting the
Secretary from limiting the number of applicants for a grant
under this subparagraph.
``(3) Specific programs to improve management practices.--
``(A) In general.--The Secretary shall make grants to
eligible entities to enable the entities to provide training
and technical assistance.
``(B) Authorized activities.--An eligible entity that
receives a grant under subparagraph (A) shall use funds made
available through the grant to provide training and technical
assistance regarding management practices using methods that
are demonstrated to promote retention of individuals who
provide direct care, such as--
``(i) the establishment of standard human resource policies
that reward high performance, including policies that provide
for improved wages and benefits on the basis of job reviews;
``(ii) the establishment of motivational and thoughtful
work organization practices;
``(iii) the creation of a workplace culture that respects
and values caregivers and their needs;
``(iv) the promotion of a workplace culture that respects
the rights of residents of an eligible entity or individuals
receiving community-based long-term care from an eligible
entity and results in improved care for the residents or the
individuals; and
``(v) the establishment of other programs that promote the
provision of high quality care, such as a continuing
education program that provides additional hours of training,
including on-the-job training, for employees who are
certified nurse aides.
``(C) Application.--To be eligible to receive a grant under
this paragraph, an eligible entity shall submit an
application to the Secretary at such time, in such manner,
and containing such information as the Secretary may require
(which may include evidence of consultation with the State in
which the eligible entity is located with respect to carrying
out activities funded under the grant).
``(D) Authority to limit number of applicants.--Nothing in
this paragraph shall be construed as prohibiting the
Secretary from limiting the number of applicants for a grant
under this paragraph.
``(4) Accountability measures.--The Secretary shall develop
accountability measures to ensure that the activities
conducted using funds made available under this subsection
benefit individuals who provide direct care and increase the
stability of the long-term care workforce.
``(5) Definitions.--In this subsection:
``(A) Community-based long-term care.--The term `community-
based long-term care' has the meaning given such term by the
Secretary.
``(B) Eligible entity.--The term `eligible entity' means
the following:
``(i) A long-term care facility.
``(ii) A community-based long-term care entity (as defined
by the Secretary).
``(b) Certified EHR Technology Grant Program.--
``(1) Grants authorized.--The Secretary is authorized to
make grants to long-term care facilities for the purpose of
assisting such entities in offsetting the costs related to
purchasing, leasing, developing, and implementing certified
EHR technology (as defined in section 1848(o)(4)) designed to
improve patient safety and reduce adverse events and health
care complications resulting from medication errors.
``(2) Use of grant funds.--Funds provided under grants
under this subsection may be used for any of the following:
``(A) Purchasing, leasing, and installing computer software
and hardware, including handheld computer technologies.
``(B) Making improvements to existing computer software and
hardware.
``(C) Making upgrades and other improvements to existing
computer software and hardware to enable e-prescribing.
``(D) Providing education and training to eligible long-
term care facility staff on the use of such technology to
implement the electronic transmission of prescription and
patient information.
``(3) Application.--
``(A) In general.--To be eligible to receive a grant under
this subsection, a long-term care facility shall submit an
application to the Secretary at such time, in such manner,
and containing such information as the Secretary may require
(which may include evidence of consultation with the State in
which the long-term care facility is located with respect to
carrying out activities funded under the grant).
``(B) Authority to limit number of applicants.--Nothing in
this subsection shall be construed as prohibiting the
Secretary from limiting the number of applicants for a grant
under this subsection.
``(4) Participation in state health exchanges.--A long-term
care facility that receives a grant under this subsection
shall, where available, participate in activities conducted
by a State or a qualified State-designated entity (as defined
in section 3013(f) of the Public Health Service Act) under a
grant under section 3013 of the Public Health Service Act to
coordinate care and for other purposes determined appropriate
by the Secretary.
``(5) Accountability measures.--The Secretary shall develop
accountability measures to ensure that the activities
conducted using funds made available under this subsection
help improve patient safety and reduce adverse events and
health care complications resulting from medication errors.
``(c) Adoption of Standards for Transactions Involving
Clinical Data by Long-Term Care Facilities.--
``(1) Standards and compatibility.--The Secretary shall
adopt electronic standards for the exchange of clinical data
by long-term care facilities, including, where available,
standards for messaging and nomenclature. Standards adopted
by the Secretary under the preceding sentence shall be
compatible with standards established under part C of title
XI, standards established under subsections (b)(2)(B)(i) and
(e)(4) of section 1860D-4, standards adopted under section
3004 of the Public Health Service Act, and general health
information technology standards.
``(2) Electronic submission of data to the secretary.--
``(A) In general.--Not later than 10 years after the date
of enactment of the Elder Justice Act of 2009, the Secretary
shall have procedures in place to accept the optional
electronic submission of clinical data by long-term care
facilities pursuant to the standards adopted under paragraph
(1).
``(B) Rule of construction.--Nothing in this subsection
shall be construed to require a long-term care facility to
submit clinical data electronically to the Secretary.
``(3) Regulations.--The Secretary shall promulgate
regulations to carry out this subsection. Such regulations
shall require a State, as a condition of the receipt of funds
under this part, to conduct such data collection and
reporting as the Secretary determines are necessary to
satisfy the requirements of this subsection.
``(d) Authorization of Appropriations.--There are
authorized to be appropriated to carry out this section--
``(1) for fiscal year 2011, $20,000,000;
``(2) for fiscal year 2012, $17,500,000; and
``(3) for each of fiscal years 2013 and 2014, $15,000,000.
``SEC. 2042. ADULT PROTECTIVE SERVICES FUNCTIONS AND GRANT
PROGRAMS.
``(a) Secretarial Responsibilities.--
``(1) In general.--The Secretary shall ensure that the
Department of Health and Human Services--
``(A) provides funding authorized by this part to State and
local adult protective services offices that investigate
reports of the abuse, neglect, and exploitation of elders;
``(B) collects and disseminates data annually relating to
the abuse, exploitation, and neglect of elders in
coordination with the Department of Justice;
``(C) develops and disseminates information on best
practices regarding, and provides training on, carrying out
adult protective services;
``(D) conducts research related to the provision of adult
protective services; and
[[Page H2094]]
``(E) provides technical assistance to States and other
entities that provide or fund the provision of adult
protective services, including through grants made under
subsections (b) and (c).
``(2) Authorization of appropriations.--There are
authorized to be appropriated to carry out this subsection,
$3,000,000 for fiscal year 2011 and $4,000,000 for each of
fiscal years 2012 through 2014.
``(b) Grants To Enhance the Provision of Adult Protective
Services.--
``(1) Establishment.--There is established an adult
protective services grant program under which the Secretary
shall annually award grants to States in the amounts
calculated under paragraph (2) for the purposes of enhancing
adult protective services provided by States and local units
of government.
``(2) Amount of payment.--
``(A) In general.--Subject to the availability of
appropriations and subparagraphs (B) and (C), the amount paid
to a State for a fiscal year under the program under this
subsection shall equal the amount appropriated for that year
to carry out this subsection multiplied by the percentage of
the total number of elders who reside in the United States
who reside in that State.
``(B) Guaranteed minimum payment amount.--
``(i) 50 states.--Subject to clause (ii), if the amount
determined under subparagraph (A) for a State for a fiscal
year is less than 0.75 percent of the amount appropriated for
such year, the Secretary shall increase such determined
amount so that the total amount paid under this subsection to
the State for the year is equal to 0.75 percent of the amount
so appropriated.
``(ii) Territories.--In the case of a State other than 1 of
the 50 States, clause (i) shall be applied as if each
reference to `0.75' were a reference to `0.1'.
``(C) Pro rata reductions.--The Secretary shall make such
pro rata reductions to the amounts described in subparagraph
(A) as are necessary to comply with the requirements of
subparagraph (B).
``(3) Authorized activities.--
``(A) Adult protective services.--Funds made available
pursuant to this subsection may only be used by States and
local units of government to provide adult protective
services and may not be used for any other purpose.
``(B) Use by agency.--Each State receiving funds pursuant
to this subsection shall provide such funds to the agency or
unit of State government having legal responsibility for
providing adult protective services within the State.
``(C) Supplement not supplant.--Each State or local unit of
government shall use funds made available pursuant to this
subsection to supplement and not supplant other Federal,
State, and local public funds expended to provide adult
protective services in the State.
``(4) State reports.--Each State receiving funds under this
subsection shall submit to the Secretary, at such time and in
such manner as the Secretary may require, a report on the
number of elders served by the grants awarded under this
subsection.
``(5) Authorization of appropriations.--There are
authorized to be appropriated to carry out this subsection,
$100,000,000 for each of fiscal years 2011 through 2014.
``(c) State Demonstration Programs.--
``(1) Establishment.--The Secretary shall award grants to
States for the purposes of conducting demonstration programs
in accordance with paragraph (2).
``(2) Demonstration programs.--Funds made available
pursuant to this subsection may be used by States and local
units of government to conduct demonstration programs that
test--
``(A) training modules developed for the purpose of
detecting or preventing elder abuse;
``(B) methods to detect or prevent financial exploitation
of elders;
``(C) methods to detect elder abuse;
``(D) whether training on elder abuse forensics enhances
the detection of elder abuse by employees of the State or
local unit of government; or
``(E) other matters relating to the detection or prevention
of elder abuse.
``(3) Application.--To be eligible to receive a grant under
this subsection, a State shall submit an application to the
Secretary at such time, in such manner, and containing such
information as the Secretary may require.
``(4) State reports.--Each State that receives funds under
this subsection shall submit to the Secretary a report at
such time, in such manner, and containing such information as
the Secretary may require on the results of the demonstration
program conducted by the State using funds made available
under this subsection.
``(5) Authorization of appropriations.--There are
authorized to be appropriated to carry out this subsection,
$25,000,000 for each of fiscal years 2011 through 2014.
``SEC. 2043. LONG-TERM CARE OMBUDSMAN PROGRAM GRANTS AND
TRAINING.
``(a) Grants To Support the Long-Term Care Ombudsman
Program.--
``(1) In general.--The Secretary shall make grants to
eligible entities with relevant expertise and experience in
abuse and neglect in long-term care facilities or long-term
care ombudsman programs and responsibilities, for the purpose
of--
``(A) improving the capacity of State long-term care
ombudsman programs to respond to and resolve complaints about
abuse and neglect;
``(B) conducting pilot programs with State long-term care
ombudsman offices or local ombudsman entities; and
``(C) providing support for such State long-term care
ombudsman programs and such pilot programs (such as through
the establishment of a national long-term care ombudsman
resource center).
``(2) Authorization of appropriations.--There are
authorized to be appropriated to carry out this subsection--
``(A) for fiscal year 2011, $5,000,000;
``(B) for fiscal year 2012, $7,500,000; and
``(C) for each of fiscal years 2013 and 2014, $10,000,000.
``(b) Ombudsman Training Programs.--
``(1) In general.--The Secretary shall establish programs
to provide and improve ombudsman training with respect to
elder abuse, neglect, and exploitation for national
organizations and State long-term care ombudsman programs.
``(2) Authorization of appropriations.--There are
authorized to be appropriated to carry out this subsection,
for each of fiscal years 2011 through 2014, $10,000,000.
``SEC. 2044. PROVISION OF INFORMATION REGARDING, AND
EVALUATIONS OF, ELDER JUSTICE PROGRAMS.
``(a) Provision of Information.--To be eligible to receive
a grant under this part, an applicant shall agree--
``(1) except as provided in paragraph (2), to provide the
eligible entity conducting an evaluation under subsection (b)
of the activities funded through the grant with such
information as the eligible entity may require in order to
conduct such evaluation; or
``(2) in the case of an applicant for a grant under section
2041(b), to provide the Secretary with such information as
the Secretary may require to conduct an evaluation or audit
under subsection (c).
``(b) Use of Eligible Entities To Conduct Evaluations.--
``(1) Evaluations required.--Except as provided in
paragraph (2), the Secretary shall--
``(A) reserve a portion (not less than 2 percent) of the
funds appropriated with respect to each program carried out
under this part; and
``(B) use the funds reserved under subparagraph (A) to
provide assistance to eligible entities to conduct
evaluations of the activities funded under each program
carried out under this part.
``(2) Certified ehr technology grant program not
included.--The provisions of this subsection shall not apply
to the certified EHR technology grant program under section
2041(b).
``(3) Authorized activities.--A recipient of assistance
described in paragraph (1)(B) shall use the funds made
available through the assistance to conduct a validated
evaluation of the effectiveness of the activities funded
under a program carried out under this part.
``(4) Applications.--To be eligible to receive assistance
under paragraph (1)(B), an entity shall submit an application
to the Secretary at such time, in such manner, and containing
such information as the Secretary may require, including a
proposal for the evaluation.
``(5) Reports.--Not later than a date specified by the
Secretary, an eligible entity receiving assistance under
paragraph (1)(B) shall submit to the Secretary, the Committee
on Ways and Means and the Committee on Energy and Commerce of
the House of Representatives, and the Committee on Finance of
the Senate a report containing the results of the evaluation
conducted using such assistance together with such
recommendations as the entity determines to be appropriate.
``(c) Evaluations and Audits of Certified EHR Technology
Grant Program by the Secretary.--
``(1) Evaluations.--The Secretary shall conduct an
evaluation of the activities funded under the certified EHR
technology grant program under section 2041(b). Such
evaluation shall include an evaluation of whether the funding
provided under the grant is expended only for the purposes
for which it is made.
``(2) Audits.--The Secretary shall conduct appropriate
audits of grants made under section 2041(b).
``SEC. 2045. REPORT.
``Not later than October 1, 2014, the Secretary shall
submit to the Elder Justice Coordinating Council established
under section 2021, the Committee on Ways and Means and the
Committee on Energy and Commerce of the House of
Representatives, and the Committee on Finance of the Senate a
report--
``(1) compiling, summarizing, and analyzing the information
contained in the State reports submitted under subsections
(b)(4) and (c)(4) of section 2042; and
``(2) containing such recommendations for legislative or
administrative action as the Secretary determines to be
appropriate.
``SEC. 2046. RULE OF CONSTRUCTION.
``Nothing in this subtitle shall be construed as--
``(1) limiting any cause of action or other relief related
to obligations under this subtitle that is available under
the law of any State, or political subdivision thereof; or
``(2) creating a private cause of action for a violation of
this subtitle.''.
(2) Option for state plan under program for temporary
assistance for needy families.--
(A) In general.--Section 402(a)(1)(B) of the Social
Security Act (42 U.S.C. 602(a)(1)(B)) is amended by adding at
the end the following new clause:
``(v) The document shall indicate whether the State intends
to assist individuals to train for, seek, and maintain
employment--
``(I) providing direct care in a long-term care facility
(as such terms are defined under section 2011); or
``(II) in other occupations related to elder care
determined appropriate by the State for which the State
identifies an unmet need for service personnel,
and, if so, shall include an overview of such assistance.''.
(B) Effective date.--The amendment made by subparagraph (A)
shall take effect on January 1, 2011.
[[Page H2095]]
(b) Protecting Residents of Long-Term Care Facilities.--
(1) National training institute for surveyors.--
(A) In general.--The Secretary of Health and Human Services
shall enter into a contract with an entity for the purpose of
establishing and operating a National Training Institute for
Federal and State surveyors. Such Institute shall provide and
improve the training of surveyors with respect to
investigating allegations of abuse, neglect, and
misappropriation of property in programs and long-term care
facilities that receive payments under title XVIII or XIX of
the Social Security Act.
(B) Activities carried out by the institute.--The contract
entered into under subparagraph (A) shall require the
Institute established and operated under such contract to
carry out the following activities:
(i) Assess the extent to which State agencies use
specialized surveyors for the investigation of reported
allegations of abuse, neglect, and misappropriation of
property in such programs and long-term care facilities.
(ii) Evaluate how the competencies of surveyors may be
improved to more effectively investigate reported allegations
of such abuse, neglect, and misappropriation of property, and
provide feedback to Federal and State agencies on the
evaluations conducted.
(iii) Provide a national program of training, tools, and
technical assistance to Federal and State surveyors on
investigating reports of such abuse, neglect, and
misappropriation of property.
(iv) Develop and disseminate information on best practices
for the investigation of such abuse, neglect, and
misappropriation of property.
(v) Assess the performance of State complaint intake
systems, in order to ensure that the intake of complaints
occurs 24 hours per day, 7 days a week (including holidays).
(vi) To the extent approved by the Secretary of Health and
Human Services, provide a national 24 hours per day, 7 days a
week (including holidays), back-up system to State complaint
intake systems in order to ensure optimum national
responsiveness to complaints of such abuse, neglect, and
misappropriation of property.
(vii) Analyze and report annually on the following:
(I) The total number and sources of complaints of such
abuse, neglect, and misappropriation of property.
(II) The extent to which such complaints are referred to
law enforcement agencies.
(III) General results of Federal and State investigations
of such complaints.
(viii) Conduct a national study of the cost to State
agencies of conducting complaint investigations of skilled
nursing facilities and nursing facilities under sections 1819
and 1919, respectively, of the Social Security Act (42 U.S.C.
1395i-3; 1396r), and making recommendations to the Secretary
of Health and Human Services with respect to options to
increase the efficiency and cost-effectiveness of such
investigations.
(C) Authorization.--There are authorized to be appropriated
to carry out this paragraph, for the period of fiscal years
2011 through 2014, $12,000,000.
(2) Grants to state survey agencies.--
(A) In general.--The Secretary of Health and Human Services
shall make grants to State agencies that perform surveys of
skilled nursing facilities or nursing facilities under
sections 1819 or 1919, respectively, of the Social Security
Act (42 U.S.C. 1395i-3; 1395r).
(B) Use of funds.--A grant awarded under subparagraph (A)
shall be used for the purpose of designing and implementing
complaint investigations systems that--
(i) promptly prioritize complaints in order to ensure a
rapid response to the most serious and urgent complaints;
(ii) respond to complaints with optimum effectiveness and
timeliness; and
(iii) optimize the collaboration between local authorities,
consumers, and providers, including--
(I) such State agency;
(II) the State Long-Term Care Ombudsman;
(III) local law enforcement agencies;
(IV) advocacy and consumer organizations;
(V) State aging units;
(VI) Area Agencies on Aging; and
(VII) other appropriate entities.
(C) Authorization.--There are authorized to be appropriated
to carry out this paragraph, for each of fiscal years 2011
through 2014, $5,000,000.
(3) Reporting of crimes in federally funded long-term care
facilities.--Part A of title XI of the Social Security Act
(42 U.S.C. 1301 et seq.), as amended by section 6005, is
amended by inserting after section 1150A the following new
section:
``reporting to law enforcement of crimes occurring in federally funded
long-term care facilities
``Sec. 1150B. (a) Determination and Notification.--
``(1) Determination.--The owner or operator of each long-
term care facility that receives Federal funds under this Act
shall annually determine whether the facility received at
least $10,000 in such Federal funds during the preceding
year.
``(2) Notification.--If the owner or operator determines
under paragraph (1) that the facility received at least
$10,000 in such Federal funds during the preceding year, such
owner or operator shall annually notify each covered
individual (as defined in paragraph (3)) of that individual's
obligation to comply with the reporting requirements
described in subsection (b).
``(3) Covered individual defined.--In this section, the
term `covered individual' means each individual who is an
owner, operator, employee, manager, agent, or contractor of a
long-term care facility that is the subject of a
determination described in paragraph (1).
``(b) Reporting Requirements.--
``(1) In general.--Each covered individual shall report to
the Secretary and 1 or more law enforcement entities for the
political subdivision in which the facility is located any
reasonable suspicion of a crime (as defined by the law of the
applicable political subdivision) against any individual who
is a resident of, or is receiving care from, the facility.
``(2) Timing.--If the events that cause the suspicion--
``(A) result in serious bodily injury, the individual shall
report the suspicion immediately, but not later than 2 hours
after forming the suspicion; and
``(B) do not result in serious bodily injury, the
individual shall report the suspicion not later than 24 hours
after forming the suspicion.
``(c) Penalties.--
``(1) In general.--If a covered individual violates
subsection (b)--
``(A) the covered individual shall be subject to a civil
money penalty of not more than $200,000; and
``(B) the Secretary may make a determination in the same
proceeding to exclude the covered individual from
participation in any Federal health care program (as defined
in section 1128B(f)).
``(2) Increased harm.--If a covered individual violates
subsection (b) and the violation exacerbates the harm to the
victim of the crime or results in harm to another
individual--
``(A) the covered individual shall be subject to a civil
money penalty of not more than $300,000; and
``(B) the Secretary may make a determination in the same
proceeding to exclude the covered individual from
participation in any Federal health care program (as defined
in section 1128B(f)).
``(3) Excluded individual.--During any period for which a
covered individual is classified as an excluded individual
under paragraph (1)(B) or (2)(B), a long-term care facility
that employs such individual shall be ineligible to receive
Federal funds under this Act.
``(4) Extenuating circumstances.--
``(A) In general.--The Secretary may take into account the
financial burden on providers with underserved populations in
determining any penalty to be imposed under this subsection.
``(B) Underserved population defined.--In this paragraph,
the term `underserved population' means the population of an
area designated by the Secretary as an area with a shortage
of elder justice programs or a population group designated by
the Secretary as having a shortage of such programs. Such
areas or groups designated by the Secretary may include--
``(i) areas or groups that are geographically isolated
(such as isolated in a rural area);
``(ii) racial and ethnic minority populations; and
``(iii) populations underserved because of special needs
(such as language barriers, disabilities, alien status, or
age).
``(d) Additional Penalties for Retaliation.--
``(1) In general.--A long-term care facility may not--
``(A) discharge, demote, suspend, threaten, harass, or deny
a promotion or other employment-related benefit to an
employee, or in any other manner discriminate against an
employee in the terms and conditions of employment because of
lawful acts done by the employee; or
``(B) file a complaint or a report against a nurse or other
employee with the appropriate State professional disciplinary
agency because of lawful acts done by the nurse or employee,
for making a report, causing a report to be made, or for
taking steps in furtherance of making a report pursuant to
subsection (b)(1).
``(2) Penalties for retaliation.--If a long-term care
facility violates subparagraph (A) or (B) of paragraph (1)
the facility shall be subject to a civil money penalty of not
more than $200,000 or the Secretary may classify the entity
as an excluded entity for a period of 2 years pursuant to
section 1128(b), or both.
``(3) Requirement to post notice.--Each long-term care
facility shall post conspicuously in an appropriate location
a sign (in a form specified by the Secretary) specifying the
rights of employees under this section. Such sign shall
include a statement that an employee may file a complaint
with the Secretary against a long-term care facility that
violates the provisions of this subsection and information
with respect to the manner of filing such a complaint.
``(e) Procedure.--The provisions of section 1128A (other
than subsections (a) and (b) and the second sentence of
subsection (f)) shall apply to a civil money penalty or
exclusion under this section in the same manner as such
provisions apply to a penalty or proceeding under section
1128A(a).
``(f) Definitions.--In this section, the terms `elder
justice', `long-term care facility', and `law enforcement'
have the meanings given those terms in section 2011.''.
(c) National Nurse Aide Registry.--
(1) Definition of nurse aide.--In this subsection, the term
``nurse aide'' has the meaning given that term in sections
1819(b)(5)(F) and 1919(b)(5)(F) of the Social Security Act
(42 U.S.C. 1395i-3(b)(5)(F); 1396r(b)(5)(F)).
(2) Study and report.--
(A) In general.--The Secretary, in consultation with
appropriate government agencies and private sector
organizations, shall conduct a study on establishing a
national nurse aide registry.
(B) Areas evaluated.--The study conducted under this
subsection shall include an evaluation of--
[[Page H2096]]
(i) who should be included in the registry;
(ii) how such a registry would comply with Federal and
State privacy laws and regulations;
(iii) how data would be collected for the registry;
(iv) what entities and individuals would have access to the
data collected;
(v) how the registry would provide appropriate information
regarding violations of Federal and State law by individuals
included in the registry;
(vi) how the functions of a national nurse aide registry
would be coordinated with the nationwide program for national
and State background checks on direct patient access
employees of long-term care facilities and providers under
section 4301; and
(vii) how the information included in State nurse aide
registries developed and maintained under sections 1819(e)(2)
and 1919(e)(2) of the Social Security Act (42 U.S.C. 1395i-
3(e)(2); 1396r(e)(2)(2)) would be provided as part of a
national nurse aide registry.
(C) Considerations.--In conducting the study and preparing
the report required under this subsection, the Secretary
shall take into consideration the findings and conclusions of
relevant reports and other relevant resources, including the
following:
(i) The Department of Health and Human Services Office of
Inspector General Report, Nurse Aide Registries: State
Compliance and Practices (February 2005).
(ii) The General Accounting Office (now known as the
Government Accountability Office) Report, Nursing Homes: More
Can Be Done to Protect Residents from Abuse (March 2002).
(iii) The Department of Health and Human Services Office of
the Inspector General Report, Nurse Aide Registries: Long-
Term Care Facility Compliance and Practices (July 2005).
(iv) The Department of Health and Human Services Health
Resources and Services Administration Report, Nursing Aides,
Home Health Aides, and Related Health Care Occupations--
National and Local Workforce Shortages and Associated Data
Needs (2004) (in particular with respect to chapter 7 and
appendix F).
(v) The 2001 Report to CMS from the School of Rural Public
Health, Texas A&M University, Preventing Abuse and Neglect in
Nursing Homes: The Role of Nurse Aide Registries.
(vi) Information included in State nurse aide registries
developed and maintained under sections 1819(e)(2) and
1919(e)(2) of the Social Security Act (42 U.S.C. 1395i-
3(e)(2); 1396r(e)(2)(2)).
(D) Report.--Not later than 18 months after the date of
enactment of this Act, the Secretary shall submit to the
Elder Justice Coordinating Council established under section
2021 of the Social Security Act, as added by section 1805(a),
the Committee on Finance of the Senate, and the Committee on
Ways and Means and the Committee on Energy and Commerce of
the House of Representatives a report containing the findings
and recommendations of the study conducted under this
paragraph.
(E) Funding limitation.--Funding for the study conducted
under this subsection shall not exceed $500,000.
(3) Congressional action.--After receiving the report
submitted by the Secretary under paragraph (2)(D), the
Committee on Finance of the Senate and the Committee on Ways
and Means and the Committee on Energy and Commerce of the
House of Representatives shall, as they deem appropriate,
take action based on the recommendations contained in the
report.
(4) Authorization of appropriations.--There are authorized
to be appropriated such sums as are necessary for the purpose
of carrying out this subsection.
(d) Conforming Amendments.--
(1) Title xx.--Title XX of the Social Security Act (42
U.S.C. 1397 et seq.), as amended by section 6703(a), is
amended--
(A) in the heading of section 2001, by striking ``title''
and inserting ``subtitle''; and
(B) in subtitle 1, by striking ``this title'' each place it
appears and inserting ``this subtitle''.
(2) Title iv.--Title IV of the Social Security Act (42
U.S.C. 601 et seq.) is amended--
(A) in section 404(d)--
(i) in paragraphs (1)(A), (2)(A), and (3)(B), by inserting
``subtitle 1 of'' before ``title XX'' each place it appears;
(ii) in the heading of paragraph (2), by inserting
``subtitle 1 of'' before ``title xx''; and
(iii) in the heading of paragraph (3)(B), by inserting
``subtitle 1 of'' before ``title xx''; and
(B) in sections 422(b), 471(a)(4), 472(h)(1), and
473(b)(2), by inserting ``subtitle 1 of'' before ``title XX''
each place it appears.
(3) Title xi.--Title XI of the Social Security Act (42
U.S.C. 1301 et seq.) is amended--
(A) in section 1128(h)(3)--
(i) by inserting ``subtitle 1 of'' before ``title XX''; and
(ii) by striking ``such title'' and inserting ``such
subtitle''; and
(B) in section 1128A(i)(1), by inserting ``subtitle 1 of''
before ``title XX''.
Subtitle I--Sense of the Senate Regarding Medical Malpractice
SEC. 6801. SENSE OF THE SENATE REGARDING MEDICAL MALPRACTICE.
It is the sense of the Senate that--
(1) health care reform presents an opportunity to address
issues related to medical malpractice and medical liability
insurance;
(2) States should be encouraged to develop and test
alternatives to the existing civil litigation system as a way
of improving patient safety, reducing medical errors,
encouraging the efficient resolution of disputes, increasing
the availability of prompt and fair resolution of disputes,
and improving access to liability insurance, while preserving
an individual's right to seek redress in court; and
(3) Congress should consider establishing a State
demonstration program to evaluate alternatives to the
existing civil litigation system with respect to the
resolution of medical malpractice claims.
TITLE VII--IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES
Subtitle A--Biologics Price Competition and Innovation
SEC. 7001. SHORT TITLE.
(a) In General.--This subtitle may be cited as the
``Biologics Price Competition and Innovation Act of 2009''.
(b) Sense of the Senate.--It is the sense of the Senate
that a biosimilars pathway balancing innovation and consumer
interests should be established.
SEC. 7002. APPROVAL PATHWAY FOR BIOSIMILAR BIOLOGICAL
PRODUCTS.
(a) Licensure of Biological Products as Biosimilar or
Interchangeable.--Section 351 of the Public Health Service
Act (42 U.S.C. 262) is amended--
(1) in subsection (a)(1)(A), by inserting ``under this
subsection or subsection (k)'' after ``biologics license'';
and
(2) by adding at the end the following:
``(k) Licensure of Biological Products as Biosimilar or
Interchangeable.--
``(1) In general.--Any person may submit an application for
licensure of a biological product under this subsection.
``(2) Content.--
``(A) In general.--
``(i) Required information.--An application submitted under
this subsection shall include information demonstrating
that--
``(I) the biological product is biosimilar to a reference
product based upon data derived from--
``(aa) analytical studies that demonstrate that the
biological product is highly similar to the reference product
notwithstanding minor differences in clinically inactive
components;
``(bb) animal studies (including the assessment of
toxicity); and
``(cc) a clinical study or studies (including the
assessment of immunogenicity and pharmacokinetics or
pharmacodynamics) that are sufficient to demonstrate safety,
purity, and potency in 1 or more appropriate conditions of
use for which the reference product is licensed and intended
to be used and for which licensure is sought for the
biological product;
``(II) the biological product and reference product utilize
the same mechanism or mechanisms of action for the condition
or conditions of use prescribed, recommended, or suggested in
the proposed labeling, but only to the extent the mechanism
or mechanisms of action are known for the reference product;
``(III) the condition or conditions of use prescribed,
recommended, or suggested in the labeling proposed for the
biological product have been previously approved for the
reference product;
``(IV) the route of administration, the dosage form, and
the strength of the biological product are the same as those
of the reference product; and
``(V) the facility in which the biological product is
manufactured, processed, packed, or held meets standards
designed to assure that the biological product continues to
be safe, pure, and potent.
``(ii) Determination by secretary.--The Secretary may
determine, in the Secretary's discretion, that an element
described in clause (i)(I) is unnecessary in an application
submitted under this subsection.
``(iii) Additional information.--An application submitted
under this subsection--
``(I) shall include publicly-available information
regarding the Secretary's previous determination that the
reference product is safe, pure, and potent; and
``(II) may include any additional information in support of
the application, including publicly-available information
with respect to the reference product or another biological
product.
``(B) Interchangeability.--An application (or a supplement
to an application) submitted under this subsection may
include information demonstrating that the biological product
meets the standards described in paragraph (4).
``(3) Evaluation by secretary.--Upon review of an
application (or a supplement to an application) submitted
under this subsection, the Secretary shall license the
biological product under this subsection if--
``(A) the Secretary determines that the information
submitted in the application (or the supplement) is
sufficient to show that the biological product--
``(i) is biosimilar to the reference product; or
``(ii) meets the standards described in paragraph (4), and
therefore is interchangeable with the reference product; and
``(B) the applicant (or other appropriate person) consents
to the inspection of the facility that is the subject of the
application, in accordance with subsection (c).
``(4) Safety standards for determining
interchangeability.--Upon review of an application submitted
under this subsection or any supplement to such application,
the Secretary shall determine the biological product to be
interchangeable with the reference product if the Secretary
determines that the information submitted in the application
(or a supplement to such application) is sufficient to show
that--
``(A) the biological product--
``(i) is biosimilar to the reference product; and
``(ii) can be expected to produce the same clinical result
as the reference product in any given patient; and
``(B) for a biological product that is administered more
than once to an individual, the risk in terms of safety or
diminished efficacy of alternating or switching between use
of the biological product and the reference product is not
greater than the risk of using the reference product without
such alternation or switch.
``(5) General rules.--
[[Page H2097]]
``(A) One reference product per application.--A biological
product, in an application submitted under this subsection,
may not be evaluated against more than 1 reference product.
``(B) Review.--An application submitted under this
subsection shall be reviewed by the division within the Food
and Drug Administration that is responsible for the review
and approval of the application under which the reference
product is licensed.
``(C) Risk evaluation and mitigation strategies.--The
authority of the Secretary with respect to risk evaluation
and mitigation strategies under the Federal Food, Drug, and
Cosmetic Act shall apply to biological products licensed
under this subsection in the same manner as such authority
applies to biological products licensed under subsection (a).
``(6) Exclusivity for first interchangeable biological
product.--Upon review of an application submitted under this
subsection relying on the same reference product for which a
prior biological product has received a determination of
interchangeability for any condition of use, the Secretary
shall not make a determination under paragraph (4) that the
second or subsequent biological product is interchangeable
for any condition of use until the earlier of--
``(A) 1 year after the first commercial marketing of the
first interchangeable biosimilar biological product to be
approved as interchangeable for that reference product;
``(B) 18 months after--
``(i) a final court decision on all patents in suit in an
action instituted under subsection (l)(6) against the
applicant that submitted the application for the first
approved interchangeable biosimilar biological product; or
``(ii) the dismissal with or without prejudice of an action
instituted under subsection (l)(6) against the applicant that
submitted the application for the first approved
interchangeable biosimilar biological product; or
``(C)(i) 42 months after approval of the first
interchangeable biosimilar biological product if the
applicant that submitted such application has been sued under
subsection (l)(6) and such litigation is still ongoing within
such 42-month period; or
``(ii) 18 months after approval of the first
interchangeable biosimilar biological product if the
applicant that submitted such application has not been sued
under subsection (l)(6).
For purposes of this paragraph, the term `final court
decision' means a final decision of a court from which no
appeal (other than a petition to the United States Supreme
Court for a writ of certiorari) has been or can be taken.
``(7) Exclusivity for reference product.--
``(A) Effective date of biosimilar application approval.--
Approval of an application under this subsection may not be
made effective by the Secretary until the date that is 12
years after the date on which the reference product was first
licensed under subsection (a).
``(B) Filing period.--An application under this subsection
may not be submitted to the Secretary until the date that is
4 years after the date on which the reference product was
first licensed under subsection (a).
``(C) First licensure.--Subparagraphs (A) and (B) shall not
apply to a license for or approval of--
``(i) a supplement for the biological product that is the
reference product; or
``(ii) a subsequent application filed by the same sponsor
or manufacturer of the biological product that is the
reference product (or a licensor, predecessor in interest, or
other related entity) for--
``(I) a change (not including a modification to the
structure of the biological product) that results in a new
indication, route of administration, dosing schedule, dosage
form, delivery system, delivery device, or strength; or
``(II) a modification to the structure of the biological
product that does not result in a change in safety, purity,
or potency.
``(8) Guidance documents.--
``(A) In general.--The Secretary may, after opportunity for
public comment, issue guidance in accordance, except as
provided in subparagraph (B)(i), with section 701(h) of the
Federal Food, Drug, and Cosmetic Act with respect to the
licensure of a biological product under this subsection. Any
such guidance may be general or specific.
``(B) Public comment.--
``(i) In general.--The Secretary shall provide the public
an opportunity to comment on any proposed guidance issued
under subparagraph (A) before issuing final guidance.
``(ii) Input regarding most valuable guidance.--The
Secretary shall establish a process through which the public
may provide the Secretary with input regarding priorities for
issuing guidance.
``(C) No requirement for application consideration.--The
issuance (or non-issuance) of guidance under subparagraph (A)
shall not preclude the review of, or action on, an
application submitted under this subsection.
``(D) Requirement for product class-specific guidance.--If
the Secretary issues product class-specific guidance under
subparagraph (A), such guidance shall include a description
of--
``(i) the criteria that the Secretary will use to determine
whether a biological product is highly similar to a reference
product in such product class; and
``(ii) the criteria, if available, that the Secretary will
use to determine whether a biological product meets the
standards described in paragraph (4).
``(E) Certain product classes.--
``(i) Guidance.--The Secretary may indicate in a guidance
document that the science and experience, as of the date of
such guidance, with respect to a product or product class
(not including any recombinant protein) does not allow
approval of an application for a license as provided under
this subsection for such product or product class.
``(ii) Modification or reversal.--The Secretary may issue a
subsequent guidance document under subparagraph (A) to modify
or reverse a guidance document under clause (i).
``(iii) No effect on ability to deny license.--Clause (i)
shall not be construed to require the Secretary to approve a
product with respect to which the Secretary has not indicated
in a guidance document that the science and experience, as
described in clause (i), does not allow approval of such an
application.
``(l) Patents.--
``(1) Confidential access to subsection (k) application.--
``(A) Application of paragraph.--Unless otherwise agreed to
by a person that submits an application under subsection (k)
(referred to in this subsection as the `subsection (k)
applicant') and the sponsor of the application for the
reference product (referred to in this subsection as the
`reference product sponsor'), the provisions of this
paragraph shall apply to the exchange of information
described in this subsection.
``(B) In general.--
``(i) Provision of confidential information.--When a
subsection (k) applicant submits an application under
subsection (k), such applicant shall provide to the persons
described in clause (ii), subject to the terms of this
paragraph, confidential access to the information required to
be produced pursuant to paragraph (2) and any other
information that the subsection (k) applicant determines, in
its sole discretion, to be appropriate (referred to in this
subsection as the `confidential information').
``(ii) Recipients of information.--The persons described in
this clause are the following:
``(I) Outside counsel.--One or more attorneys designated by
the reference product sponsor who are employees of an entity
other than the reference product sponsor (referred to in this
paragraph as the `outside counsel'), provided that such
attorneys do not engage, formally or informally, in patent
prosecution relevant or related to the reference product.
``(II) In-house counsel.--One attorney that represents the
reference product sponsor who is an employee of the reference
product sponsor, provided that such attorney does not engage,
formally or informally, in patent prosecution relevant or
related to the reference product.
``(iii) Patent owner access.--A representative of the owner
of a patent exclusively licensed to a reference product
sponsor with respect to the reference product and who has
retained a right to assert the patent or participate in
litigation concerning the patent may be provided the
confidential information, provided that the representative
informs the reference product sponsor and the subsection (k)
applicant of his or her agreement to be subject to the
confidentiality provisions set forth in this paragraph,
including those under clause (ii).
``(C) Limitation on disclosure.--No person that receives
confidential information pursuant to subparagraph (B) shall
disclose any confidential information to any other person or
entity, including the reference product sponsor employees,
outside scientific consultants, or other outside counsel
retained by the reference product sponsor, without the prior
written consent of the subsection (k) applicant, which shall
not be unreasonably withheld.
``(D) Use of confidential information.--Confidential
information shall be used for the sole and exclusive purpose
of determining, with respect to each patent assigned to or
exclusively licensed by the reference product sponsor,
whether a claim of patent infringement could reasonably be
asserted if the subsection (k) applicant engaged in the
manufacture, use, offering for sale, sale, or importation
into the United States of the biological product that is the
subject of the application under subsection (k).
``(E) Ownership of confidential information.--The
confidential information disclosed under this paragraph is,
and shall remain, the property of the subsection (k)
applicant. By providing the confidential information pursuant
to this paragraph, the subsection (k) applicant does not
provide the reference product sponsor or the outside counsel
any interest in or license to use the confidential
information, for purposes other than those specified in
subparagraph (D).
``(F) Effect of infringement action.--In the event that the
reference product sponsor files a patent infringement suit,
the use of confidential information shall continue to be
governed by the terms of this paragraph until such time as a
court enters a protective order regarding the information.
Upon entry of such order, the subsection (k) applicant may
redesignate confidential information in accordance with the
terms of that order. No confidential information shall be
included in any publicly-available complaint or other
pleading. In the event that the reference product sponsor
does not file an infringement action by the date specified in
paragraph (6), the reference product sponsor shall return or
destroy all confidential information received under this
paragraph, provided that if the reference product sponsor
opts to destroy such information, it will confirm destruction
in writing to the subsection (k) applicant.
``(G) Rule of construction.--Nothing in this paragraph
shall be construed--
``(i) as an admission by the subsection (k) applicant
regarding the validity, enforceability, or infringement of
any patent; or
``(ii) as an agreement or admission by the subsection (k)
applicant with respect to the competency, relevance, or
materiality of any confidential information.
``(H) Effect of violation.--The disclosure of any
confidential information in violation of this paragraph shall
be deemed to cause the subsection (k) applicant to suffer
irreparable harm for which there is no adequate legal remedy
and
[[Page H2098]]
the court shall consider immediate injunctive relief to be an
appropriate and necessary remedy for any violation or
threatened violation of this paragraph.
``(2) Subsection (k) application information.--Not later
than 20 days after the Secretary notifies the subsection (k)
applicant that the application has been accepted for review,
the subsection (k) applicant--
``(A) shall provide to the reference product sponsor a copy
of the application submitted to the Secretary under
subsection (k), and such other information that describes the
process or processes used to manufacture the biological
product that is the subject of such application; and
``(B) may provide to the reference product sponsor
additional information requested by or on behalf of the
reference product sponsor.
``(3) List and description of patents.--
``(A) List by reference product sponsor.--Not later than 60
days after the receipt of the application and information
under paragraph (2), the reference product sponsor shall
provide to the subsection (k) applicant--
``(i) a list of patents for which the reference product
sponsor believes a claim of patent infringement could
reasonably be asserted by the reference product sponsor, or
by a patent owner that has granted an exclusive license to
the reference product sponsor with respect to the reference
product, if a person not licensed by the reference product
sponsor engaged in the making, using, offering to sell,
selling, or importing into the United States of the
biological product that is the subject of the subsection (k)
application; and
``(ii) an identification of the patents on such list that
the reference product sponsor would be prepared to license to
the subsection (k) applicant.
``(B) List and description by subsection (k) applicant.--
Not later than 60 days after receipt of the list under
subparagraph (A), the subsection (k) applicant--
``(i) may provide to the reference product sponsor a list
of patents to which the subsection (k) applicant believes a
claim of patent infringement could reasonably be asserted by
the reference product sponsor if a person not licensed by the
reference product sponsor engaged in the making, using,
offering to sell, selling, or importing into the United
States of the biological product that is the subject of the
subsection (k) application;
``(ii) shall provide to the reference product sponsor, with
respect to each patent listed by the reference product
sponsor under subparagraph (A) or listed by the subsection
(k) applicant under clause (i)--
``(I) a detailed statement that describes, on a claim by
claim basis, the factual and legal basis of the opinion of
the subsection (k) applicant that such patent is invalid,
unenforceable, or will not be infringed by the commercial
marketing of the biological product that is the subject of
the subsection (k) application; or
``(II) a statement that the subsection (k) applicant does
not intend to begin commercial marketing of the biological
product before the date that such patent expires; and
``(iii) shall provide to the reference product sponsor a
response regarding each patent identified by the reference
product sponsor under subparagraph (A)(ii).
``(C) Description by reference product sponsor.--Not later
than 60 days after receipt of the list and statement under
subparagraph (B), the reference product sponsor shall provide
to the subsection (k) applicant a detailed statement that
describes, with respect to each patent described in
subparagraph (B)(ii)(I), on a claim by claim basis, the
factual and legal basis of the opinion of the reference
product sponsor that such patent will be infringed by the
commercial marketing of the biological product that is the
subject of the subsection (k) application and a response to
the statement concerning validity and enforceability provided
under subparagraph (B)(ii)(I).
``(4) Patent resolution negotiations.--
``(A) In general.--After receipt by the subsection (k)
applicant of the statement under paragraph (3)(C), the
reference product sponsor and the subsection (k) applicant
shall engage in good faith negotiations to agree on which, if
any, patents listed under paragraph (3) by the subsection (k)
applicant or the reference product sponsor shall be the
subject of an action for patent infringement under paragraph
(6).
``(B) Failure to reach agreement.--If, within 15 days of
beginning negotiations under subparagraph (A), the subsection
(k) applicant and the reference product sponsor fail to agree
on a final and complete list of which, if any, patents listed
under paragraph (3) by the subsection (k) applicant or the
reference product sponsor shall be the subject of an action
for patent infringement under paragraph (6), the provisions
of paragraph (5) shall apply to the parties.
``(5) Patent resolution if no agreement.--
``(A) Number of patents.--The subsection (k) applicant
shall notify the reference product sponsor of the number of
patents that such applicant will provide to the reference
product sponsor under subparagraph (B)(i)(I).
``(B) Exchange of patent lists.--
``(i) In general.--On a date agreed to by the subsection
(k) applicant and the reference product sponsor, but in no
case later than 5 days after the subsection (k) applicant
notifies the reference product sponsor under subparagraph
(A), the subsection (k) applicant and the reference product
sponsor shall simultaneously exchange--
``(I) the list of patents that the subsection (k) applicant
believes should be the subject of an action for patent
infringement under paragraph (6); and
``(II) the list of patents, in accordance with clause (ii),
that the reference product sponsor believes should be the
subject of an action for patent infringement under paragraph
(6).
``(ii) Number of patents listed by reference product
sponsor.--
``(I) In general.--Subject to subclause (II), the number of
patents listed by the reference product sponsor under clause
(i)(II) may not exceed the number of patents listed by the
subsection (k) applicant under clause (i)(I).
``(II) Exception.--If a subsection (k) applicant does not
list any patent under clause (i)(I), the reference product
sponsor may list 1 patent under clause (i)(II).
``(6) Immediate patent infringement action.--
``(A) Action if agreement on patent list.--If the
subsection (k) applicant and the reference product sponsor
agree on patents as described in paragraph (4), not later
than 30 days after such agreement, the reference product
sponsor shall bring an action for patent infringement with
respect to each such patent.
``(B) Action if no agreement on patent list.--If the
provisions of paragraph (5) apply to the parties as described
in paragraph (4)(B), not later than 30 days after the
exchange of lists under paragraph (5)(B), the reference
product sponsor shall bring an action for patent infringement
with respect to each patent that is included on such lists.
``(C) Notification and publication of complaint.--
``(i) Notification to secretary.--Not later than 30 days
after a complaint is served to a subsection (k) applicant in
an action for patent infringement described under this
paragraph, the subsection (k) applicant shall provide the
Secretary with notice and a copy of such complaint.
``(ii) Publication by secretary.--The Secretary shall
publish in the Federal Register notice of a complaint
received under clause (i).
``(7) Newly issued or licensed patents.--In the case of a
patent that--
``(A) is issued to, or exclusively licensed by, the
reference product sponsor after the date that the reference
product sponsor provided the list to the subsection (k)
applicant under paragraph (3)(A); and
``(B) the reference product sponsor reasonably believes
that, due to the issuance of such patent, a claim of patent
infringement could reasonably be asserted by the reference
product sponsor if a person not licensed by the reference
product sponsor engaged in the making, using, offering to
sell, selling, or importing into the United States of the
biological product that is the subject of the subsection (k)
application,
not later than 30 days after such issuance or licensing, the
reference product sponsor shall provide to the subsection (k)
applicant a supplement to the list provided by the reference
product sponsor under paragraph (3)(A) that includes such
patent, not later than 30 days after such supplement is
provided, the subsection (k) applicant shall provide a
statement to the reference product sponsor in accordance with
paragraph (3)(B), and such patent shall be subject to
paragraph (8).
``(8) Notice of commercial marketing and preliminary
injunction.--
``(A) Notice of commercial marketing.--The subsection (k)
applicant shall provide notice to the reference product
sponsor not later than 180 days before the date of the first
commercial marketing of the biological product licensed under
subsection (k).
``(B) Preliminary injunction.--After receiving the notice
under subparagraph (A) and before such date of the first
commercial marketing of such biological product, the
reference product sponsor may seek a preliminary injunction
prohibiting the subsection (k) applicant from engaging in the
commercial manufacture or sale of such biological product
until the court decides the issue of patent validity,
enforcement, and infringement with respect to any patent that
is--
``(i) included in the list provided by the reference
product sponsor under paragraph (3)(A) or in the list
provided by the subsection (k) applicant under paragraph
(3)(B); and
``(ii) not included, as applicable, on--
``(I) the list of patents described in paragraph (4); or
``(II) the lists of patents described in paragraph (5)(B).
``(C) Reasonable cooperation.--If the reference product
sponsor has sought a preliminary injunction under
subparagraph (B), the reference product sponsor and the
subsection (k) applicant shall reasonably cooperate to
expedite such further discovery as is needed in connection
with the preliminary injunction motion.
``(9) Limitation on declaratory judgment action.--
``(A) Subsection (k) application provided.--If a subsection
(k) applicant provides the application and information
required under paragraph (2)(A), neither the reference
product sponsor nor the subsection (k) applicant may, prior
to the date notice is received under paragraph (8)(A), bring
any action under section 2201 of title 28, United States
Code, for a declaration of infringement, validity, or
enforceability of any patent that is described in clauses (i)
and (ii) of paragraph (8)(B).
``(B) Subsequent failure to act by subsection (k)
applicant.--If a subsection (k) applicant fails to complete
an action required of the subsection (k) applicant under
paragraph (3)(B)(ii), paragraph (5), paragraph (6)(C)(i),
paragraph (7), or paragraph (8)(A), the reference product
sponsor, but not the subsection (k) applicant, may bring an
action under section 2201 of title 28, United States Code,
for a declaration of infringement, validity, or
enforceability of any patent included in the list described
in paragraph (3)(A), including as provided under paragraph
(7).
``(C) Subsection (k) application not provided.--If a
subsection (k) applicant fails to
[[Page H2099]]
provide the application and information required under
paragraph (2)(A), the reference product sponsor, but not the
subsection (k) applicant, may bring an action under section
2201 of title 28, United States Code, for a declaration of
infringement, validity, or enforceability of any patent that
claims the biological product or a use of the biological
product.''.
(b) Definitions.--Section 351(i) of the Public Health
Service Act (42 U.S.C. 262(i)) is amended--
(1) by striking ``In this section, the term `biological
product' means'' and inserting the following: ``In this
section:
``(1) The term `biological product' means'';
(2) in paragraph (1), as so designated, by inserting
``protein (except any chemically synthesized polypeptide),''
after ``allergenic product,''; and
(3) by adding at the end the following:
``(2) The term `biosimilar' or `biosimilarity', in
reference to a biological product that is the subject of an
application under subsection (k), means--
``(A) that the biological product is highly similar to the
reference product notwithstanding minor differences in
clinically inactive components; and
``(B) there are no clinically meaningful differences
between the biological product and the reference product in
terms of the safety, purity, and potency of the product.
``(3) The term `interchangeable' or `interchangeability',
in reference to a biological product that is shown to meet
the standards described in subsection (k)(4), means that the
biological product may be substituted for the reference
product without the intervention of the health care provider
who prescribed the reference product.
``(4) The term `reference product' means the single
biological product licensed under subsection (a) against
which a biological product is evaluated in an application
submitted under subsection (k).''.
(c) Conforming Amendments Relating to Patents.--
(1) Patents.--Section 271(e) of title 35, United States
Code, is amended--
(A) in paragraph (2)--
(i) in subparagraph (A), by striking ``or'' at the end;
(ii) in subparagraph (B), by adding ``or'' at the end; and
(iii) by inserting after subparagraph (B) the following:
``(C)(i) with respect to a patent that is identified in the
list of patents described in section 351(l)(3) of the Public
Health Service Act (including as provided under section
351(l)(7) of such Act), an application seeking approval of a
biological product, or
``(ii) if the applicant for the application fails to
provide the application and information required under
section 351(l)(2)(A) of such Act, an application seeking
approval of a biological product for a patent that could be
identified pursuant to section 351(l)(3)(A)(i) of such
Act,''; and
(iv) in the matter following subparagraph (C) (as added by
clause (iii)), by striking ``or veterinary biological
product'' and inserting ``, veterinary biological product, or
biological product'';
(B) in paragraph (4)--
(i) in subparagraph (B), by--
(I) striking ``or veterinary biological product'' and
inserting ``, veterinary biological product, or biological
product''; and
(II) striking ``and'' at the end;
(ii) in subparagraph (C), by--
(I) striking ``or veterinary biological product'' and
inserting ``, veterinary biological product, or biological
product''; and
(II) striking the period and inserting ``, and'';
(iii) by inserting after subparagraph (C) the following:
``(D) the court shall order a permanent injunction
prohibiting any infringement of the patent by the biological
product involved in the infringement until a date which is
not earlier than the date of the expiration of the patent
that has been infringed under paragraph (2)(C), provided the
patent is the subject of a final court decision, as defined
in section 351(k)(6) of the Public Health Service Act, in an
action for infringement of the patent under section 351(l)(6)
of such Act, and the biological product has not yet been
approved because of section 351(k)(7) of such Act.''; and
(iv) in the matter following subparagraph (D) (as added by
clause (iii)), by striking ``and (C)'' and inserting ``(C),
and (D)''; and
(C) by adding at the end the following:
``(6)(A) Subparagraph (B) applies, in lieu of paragraph
(4), in the case of a patent--
``(i) that is identified, as applicable, in the list of
patents described in section 351(l)(4) of the Public Health
Service Act or the lists of patents described in section
351(l)(5)(B) of such Act with respect to a biological
product; and
``(ii) for which an action for infringement of the patent
with respect to the biological product--
``(I) was brought after the expiration of the 30-day period
described in subparagraph (A) or (B), as applicable, of
section 351(l)(6) of such Act; or
``(II) was brought before the expiration of the 30-day
period described in subclause (I), but which was dismissed
without prejudice or was not prosecuted to judgment in good
faith.
``(B) In an action for infringement of a patent described
in subparagraph (A), the sole and exclusive remedy that may
be granted by a court, upon a finding that the making, using,
offering to sell, selling, or importation into the United
States of the biological product that is the subject of the
action infringed the patent, shall be a reasonable royalty.
``(C) The owner of a patent that should have been included
in the list described in section 351(l)(3)(A) of the Public
Health Service Act, including as provided under section
351(l)(7) of such Act for a biological product, but was not
timely included in such list, may not bring an action under
this section for infringement of the patent with respect to
the biological product.''.
(2) Conforming amendment under title 28.--Section 2201(b)
of title 28, United States Code, is amended by inserting
before the period the following: ``, or section 351 of the
Public Health Service Act''.
(d) Conforming Amendments Under the Federal Food, Drug, and
Cosmetic Act.--
(1) Content and review of applications.--Section
505(b)(5)(B) of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 355(b)(5)(B)) is amended by inserting before the
period at the end of the first sentence the following: ``or,
with respect to an applicant for approval of a biological
product under section 351(k) of the Public Health Service
Act, any necessary clinical study or studies''.
(2) New active ingredient.--Section 505B of the Federal
Food, Drug, and Cosmetic Act (21 U.S.C. 355c) is amended by
adding at the end the following:
``(n) New Active Ingredient.--
``(1) Non-interchangeable biosimilar biological product.--A
biological product that is biosimilar to a reference product
under section 351 of the Public Health Service Act, and that
the Secretary has not determined to meet the standards
described in subsection (k)(4) of such section for
interchangeability with the reference product, shall be
considered to have a new active ingredient under this
section.
``(2) Interchangeable biosimilar biological product.--A
biological product that is interchangeable with a reference
product under section 351 of the Public Health Service Act
shall not be considered to have a new active ingredient under
this section.''.
(e) Products Previously Approved Under Section 505.--
(1) Requirement to follow section 351.--Except as provided
in paragraph (2), an application for a biological product
shall be submitted under section 351 of the Public Health
Service Act (42 U.S.C. 262) (as amended by this Act).
(2) Exception.--An application for a biological product may
be submitted under section 505 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 355) if--
(A) such biological product is in a product class for which
a biological product in such product class is the subject of
an application approved under such section 505 not later than
the date of enactment of this Act; and
(B) such application--
(i) has been submitted to the Secretary of Health and Human
Services (referred to in this subtitle as the ``Secretary'')
before the date of enactment of this Act; or
(ii) is submitted to the Secretary not later than the date
that is 10 years after the date of enactment of this Act.
(3) Limitation.--Notwithstanding paragraph (2), an
application for a biological product may not be submitted
under section 505 of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. 355) if there is another biological product
approved under subsection (a) of section 351 of the Public
Health Service Act that could be a reference product with
respect to such application (within the meaning of such
section 351) if such application were submitted under
subsection (k) of such section 351.
(4) Deemed approved under section 351.--An approved
application for a biological product under section 505 of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) shall be
deemed to be a license for the biological product under such
section 351 on the date that is 10 years after the date of
enactment of this Act.
(5) Definitions.--For purposes of this subsection, the term
``biological product'' has the meaning given such term under
section 351 of the Public Health Service Act (42 U.S.C. 262)
(as amended by this Act).
(f) Follow-on Biologics User Fees.--
(1) Development of user fees for biosimilar biological
products.--
(A) In general.--Beginning not later than October 1, 2010,
the Secretary shall develop recommendations to present to
Congress with respect to the goals, and plans for meeting the
goals, for the process for the review of biosimilar
biological product applications submitted under section
351(k) of the Public Health Service Act (as added by this
Act) for the first 5 fiscal years after fiscal year 2012. In
developing such recommendations, the Secretary shall consult
with--
(i) the Committee on Health, Education, Labor, and Pensions
of the Senate;
(ii) the Committee on Energy and Commerce of the House of
Representatives;
(iii) scientific and academic experts;
(iv) health care professionals;
(v) representatives of patient and consumer advocacy
groups; and
(vi) the regulated industry.
(B) Public review of recommendations.--After negotiations
with the regulated industry, the Secretary shall--
(i) present the recommendations developed under
subparagraph (A) to the Congressional committees specified in
such subparagraph;
(ii) publish such recommendations in the Federal Register;
(iii) provide for a period of 30 days for the public to
provide written comments on such recommendations;
(iv) hold a meeting at which the public may present its
views on such recommendations; and
(v) after consideration of such public views and comments,
revise such recommendations as necessary.
(C) Transmittal of recommendations.--Not later than January
15, 2012, the Secretary shall transmit to Congress the
revised recommendations under subparagraph (B), a summary of
the
[[Page H2100]]
views and comments received under such subparagraph, and any
changes made to the recommendations in response to such views
and comments.
(2) Establishment of user fee program.--It is the sense of
the Senate that, based on the recommendations transmitted to
Congress by the Secretary pursuant to paragraph (1)(C),
Congress should authorize a program, effective on October 1,
2012, for the collection of user fees relating to the
submission of biosimilar biological product applications
under section 351(k) of the Public Health Service Act (as
added by this Act).
(3) Transitional provisions for user fees for biosimilar
biological products.--
(A) Application of the prescription drug user fee
provisions.--Section 735(1)(B) of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 379g(1)(B)) is amended by striking
``section 351'' and inserting ``subsection (a) or (k) of
section 351''.
(B) Evaluation of costs of reviewing biosimilar biological
product applications.--During the period beginning on the
date of enactment of this Act and ending on October 1, 2010,
the Secretary shall collect and evaluate data regarding the
costs of reviewing applications for biological products
submitted under section 351(k) of the Public Health Service
Act (as added by this Act) during such period.
(C) Audit.--
(i) In general.--On the date that is 2 years after first
receiving a user fee applicable to an application for a
biological product under section 351(k) of the Public Health
Service Act (as added by this Act), and on a biennial basis
thereafter until October 1, 2013, the Secretary shall perform
an audit of the costs of reviewing such applications under
such section 351(k). Such an audit shall compare--
(I) the costs of reviewing such applications under such
section 351(k) to the amount of the user fee applicable to
such applications; and
(II)(aa) such ratio determined under subclause (I); to
(bb) the ratio of the costs of reviewing applications for
biological products under section 351(a) of such Act (as
amended by this Act) to the amount of the user fee applicable
to such applications under such section 351(a).
(ii) Alteration of user fee.--If the audit performed under
clause (i) indicates that the ratios compared under subclause
(II) of such clause differ by more than 5 percent, then the
Secretary shall alter the user fee applicable to applications
submitted under such section 351(k) to more appropriately
account for the costs of reviewing such applications.
(iii) Accounting standards.--The Secretary shall perform an
audit under clause (i) in conformance with the accounting
principles, standards, and requirements prescribed by the
Comptroller General of the United States under section 3511
of title 31, United State Code, to ensure the validity of any
potential variability.
(4) Authorization of appropriations.--There is authorized
to be appropriated to carry out this subsection such sums as
may be necessary for each of fiscal years 2010 through 2012.
(g) Pediatric Studies of Biological Products.--
(1) In general.--Section 351 of the Public Health Service
Act (42 U.S.C. 262) is amended by adding at the end the
following:
``(m) Pediatric Studies.--
``(1) Application of certain provisions.--The provisions of
subsections (a), (d), (e), (f), (i), (j), (k), (l), (p), and
(q) of section 505A of the Federal Food, Drug, and Cosmetic
Act shall apply with respect to the extension of a period
under paragraphs (2) and (3) to the same extent and in the
same manner as such provisions apply with respect to the
extension of a period under subsection (b) or (c) of section
505A of the Federal Food, Drug, and Cosmetic Act.
``(2) Market exclusivity for new biological products.--If,
prior to approval of an application that is submitted under
subsection (a), the Secretary determines that information
relating to the use of a new biological product in the
pediatric population may produce health benefits in that
population, the Secretary makes a written request for
pediatric studies (which shall include a timeframe for
completing such studies), the applicant agrees to the
request, such studies are completed using appropriate
formulations for each age group for which the study is
requested within any such timeframe, and the reports thereof
are submitted and accepted in accordance with section
505A(d)(3) of the Federal Food, Drug, and Cosmetic Act--
``(A) the periods for such biological product referred to
in subsection (k)(7) are deemed to be 4 years and 6 months
rather than 4 years and 12 years and 6 months rather than 12
years; and
``(B) if the biological product is designated under section
526 for a rare disease or condition, the period for such
biological product referred to in section 527(a) is deemed to
be 7 years and 6 months rather than 7 years.
``(3) Market exclusivity for already-marketed biological
products.--If the Secretary determines that information
relating to the use of a licensed biological product in the
pediatric population may produce health benefits in that
population and makes a written request to the holder of an
approved application under subsection (a) for pediatric
studies (which shall include a timeframe for completing such
studies), the holder agrees to the request, such studies are
completed using appropriate formulations for each age group
for which the study is requested within any such timeframe,
and the reports thereof are submitted and accepted in
accordance with section 505A(d)(3) of the Federal Food, Drug,
and Cosmetic Act--
``(A) the periods for such biological product referred to
in subsection (k)(7) are deemed to be 4 years and 6 months
rather than 4 years and 12 years and 6 months rather than 12
years; and
``(B) if the biological product is designated under section
526 for a rare disease or condition, the period for such
biological product referred to in section 527(a) is deemed to
be 7 years and 6 months rather than 7 years.
``(4) Exception.--The Secretary shall not extend a period
referred to in paragraph (2)(A), (2)(B), (3)(A), or (3)(B) if
the determination under section 505A(d)(3) is made later than
9 months prior to the expiration of such period.''.
(2) Studies regarding pediatric research.--
(A) Program for pediatric study of drugs.--Subsection
(a)(1) of section 409I of the Public Health Service Act (42
U.S.C. 284m) is amended by inserting ``, biological
products,'' after ``including drugs''.
(B) Institute of medicine study.--Section 505A(p) of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355b(p)) is
amended by striking paragraphs (4) and (5) and inserting the
following:
``(4) review and assess the number and importance of
biological products for children that are being tested as a
result of the amendments made by the Biologics Price
Competition and Innovation Act of 2009 and the importance for
children, health care providers, parents, and others of
labeling changes made as a result of such testing;
``(5) review and assess the number, importance, and
prioritization of any biological products that are not being
tested for pediatric use; and
``(6) offer recommendations for ensuring pediatric testing
of biological products, including consideration of any
incentives, such as those provided under this section or
section 351(m) of the Public Health Service Act.''.
(h) Orphan Products.--If a reference product, as defined in
section 351 of the Public Health Service Act (42 U.S.C. 262)
(as amended by this Act) has been designated under section
526 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C.
360bb) for a rare disease or condition, a biological product
seeking approval for such disease or condition under
subsection (k) of such section 351 as biosimilar to, or
interchangeable with, such reference product may be licensed
by the Secretary only after the expiration for such reference
product of the later of--
(1) the 7-year period described in section 527(a) of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360cc(a));
and
(2) the 12-year period described in subsection (k)(7) of
such section 351.
SEC. 7003. SAVINGS.
(a) Determination.--The Secretary of the Treasury, in
consultation with the Secretary of Health and Human Services,
shall for each fiscal year determine the amount of savings to
the Federal Government as a result of the enactment of this
subtitle.
(b) Use.--Notwithstanding any other provision of this
subtitle (or an amendment made by this subtitle), the savings
to the Federal Government generated as a result of the
enactment of this subtitle shall be used for deficit
reduction.
Subtitle B--More Affordable Medicines for Children and Underserved
Communities
SEC. 7101. EXPANDED PARTICIPATION IN 340B PROGRAM.
(a) Expansion of Covered Entities Receiving Discounted
Prices.--Section 340B(a)(4) of the Public Health Service Act
(42 U.S.C. 256b(a)(4)) is amended by adding at the end the
following:
``(M) A children's hospital excluded from the Medicare
prospective payment system pursuant to section
1886(d)(1)(B)(iii) of the Social Security Act, or a free-
standing cancer hospital excluded from the Medicare
prospective payment system pursuant to section
1886(d)(1)(B)(v) of the Social Security Act, that would meet
the requirements of subparagraph (L), including the
disproportionate share adjustment percentage requirement
under clause (ii) of such subparagraph, if the hospital were
a subsection (d) hospital as defined by section 1886(d)(1)(B)
of the Social Security Act.
``(N) An entity that is a critical access hospital (as
determined under section 1820(c)(2) of the Social Security
Act), and that meets the requirements of subparagraph (L)(i).
``(O) An entity that is a rural referral center, as defined
by section 1886(d)(5)(C)(i) of the Social Security Act, or a
sole community hospital, as defined by section
1886(d)(5)(C)(iii) of such Act, and that both meets the
requirements of subparagraph (L)(i) and has a
disproportionate share adjustment percentage equal to or
greater than 8 percent.''.
(b) Extension of Discount to Inpatient Drugs.--Section 340B
of the Public Health Service Act (42 U.S.C. 256b) is
amended--
(1) in paragraphs (2), (5), (7), and (9) of subsection (a),
by striking ``outpatient'' each place it appears; and
(2) in subsection (b)--
(A) by striking ``Other Definition'' and all that follows
through ``In this section'' and inserting the following:
``Other Definitions.--
``(1) In general.--In this section''; and
(B) by adding at the end the following new paragraph:
``(2) Covered drug.--In this section, the term `covered
drug'--
``(A) means a covered outpatient drug (as defined in
section 1927(k)(2) of the Social Security Act); and
``(B) includes, notwithstanding paragraph (3)(A) of section
1927(k) of such Act, a drug used in connection with an
inpatient or outpatient service provided by a hospital
described in subparagraph (L), (M), (N), or (O) of subsection
(a)(4) that is enrolled to participate in the drug discount
program under this section.''.
(c) Prohibition on Group Purchasing Arrangements.--Section
340B(a) of the Public Health Service Act (42 U.S.C. 256b(a))
is amended--
(1) in paragraph (4)(L)--
(A) in clause (i), by adding ``and'' at the end;
(B) in clause (ii), by striking ``; and'' and inserting a
period; and
[[Page H2101]]
(C) by striking clause (iii); and
(2) in paragraph (5), as amended by subsection (b)--
(A) by redesignating subparagraphs (C) and (D) as
subparagraphs (D) and (E); respectively; and
(B) by inserting after subparagraph (B), the following:
``(C) Prohibition on group purchasing arrangements.--
``(i) In general.--A hospital described in subparagraph
(L), (M), (N), or (O) of paragraph (4) shall not obtain
covered outpatient drugs through a group purchasing
organization or other group purchasing arrangement, except as
permitted or provided for pursuant to clauses (ii) or (iii).
``(ii) Inpatient drugs.--Clause (i) shall not apply to
drugs purchased for inpatient use.
``(iii) Exceptions.--The Secretary shall establish
reasonable exceptions to clause (i)--
``(I) with respect to a covered outpatient drug that is
unavailable to be purchased through the program under this
section due to a drug shortage problem, manufacturer
noncompliance, or any other circumstance beyond the
hospital's control;
``(II) to facilitate generic substitution when a generic
covered outpatient drug is available at a lower price; or
``(III) to reduce in other ways the administrative burdens
of managing both inventories of drugs subject to this section
and inventories of drugs that are not subject to this
section, so long as the exceptions do not create a duplicate
discount problem in violation of subparagraph (A) or a
diversion problem in violation of subparagraph (B).
``(iv) Purchasing arrangements for inpatient drugs.--The
Secretary shall ensure that a hospital described in
subparagraph (L), (M), (N), or (O) of subsection (a)(4) that
is enrolled to participate in the drug discount program under
this section shall have multiple options for purchasing
covered drugs for inpatients, including by utilizing a group
purchasing organization or other group purchasing
arrangement, establishing and utilizing its own group
purchasing program, purchasing directly from a manufacturer,
and any other purchasing arrangements that the Secretary
determines is appropriate to ensure access to drug discount
pricing under this section for inpatient drugs taking into
account the particular needs of small and rural hospitals.''.
(d) Medicaid Credits on Inpatient Drugs.--Section 340B of
the Public Health Service Act (42 U.S.C. 256b) is amended by
striking subsection (c) and inserting the following:
``(c) Medicaid Credit.--Not later than 90 days after the
date of filing of the hospital's most recently filed Medicare
cost report, the hospital shall issue a credit as determined
by the Secretary to the State Medicaid program for inpatient
covered drugs provided to Medicaid recipients.''.
(e) Effective Dates.--
(1) In general.--The amendments made by this section and
section 7102 shall take effect on January 1, 2010, and shall
apply to drugs purchased on or after January 1, 2010.
(2) Effectiveness.--The amendments made by this section and
section 7102 shall be effective and shall be taken into
account in determining whether a manufacturer is deemed to
meet the requirements of section 340B(a) of the Public Health
Service Act (42 U.S.C. 256b(a)), notwithstanding any other
provision of law.
SEC. 7102. IMPROVEMENTS TO 340B PROGRAM INTEGRITY.
(a) Integrity Improvements.--Subsection (d) of section 340B
of the Public Health Service Act (42 U.S.C. 256b) is amended
to read as follows:
``(d) Improvements in Program Integrity.--
``(1) Manufacturer compliance.--
``(A) In general.--From amounts appropriated under
paragraph (4), the Secretary shall provide for improvements
in compliance by manufacturers with the requirements of this
section in order to prevent overcharges and other violations
of the discounted pricing requirements specified in this
section.
``(B) Improvements.--The improvements described in
subparagraph (A) shall include the following:
``(i) The development of a system to enable the Secretary
to verify the accuracy of ceiling prices calculated by
manufacturers under subsection (a)(1) and charged to covered
entities, which shall include the following:
``(I) Developing and publishing through an appropriate
policy or regulatory issuance, precisely defined standards
and methodology for the calculation of ceiling prices under
such subsection.
``(II) Comparing regularly the ceiling prices calculated by
the Secretary with the quarterly pricing data that is
reported by manufacturers to the Secretary.
``(III) Performing spot checks of sales transactions by
covered entities.
``(IV) Inquiring into the cause of any pricing
discrepancies that may be identified and either taking, or
requiring manufacturers to take, such corrective action as is
appropriate in response to such price discrepancies.
``(ii) The establishment of procedures for manufacturers to
issue refunds to covered entities in the event that there is
an overcharge by the manufacturers, including the following:
``(I) Providing the Secretary with an explanation of why
and how the overcharge occurred, how the refunds will be
calculated, and to whom the refunds will be issued.
``(II) Oversight by the Secretary to ensure that the
refunds are issued accurately and within a reasonable period
of time, both in routine instances of retroactive adjustment
to relevant pricing data and exceptional circumstances such
as erroneous or intentional overcharging for covered drugs.
``(iii) The provision of access through the Internet
website of the Department of Health and Human Services to the
applicable ceiling prices for covered drugs as calculated and
verified by the Secretary in accordance with this section, in
a manner (such as through the use of password protection)
that limits such access to covered entities and adequately
assures security and protection of privileged pricing data
from unauthorized re-disclosure.
``(iv) The development of a mechanism by which--
``(I) rebates and other discounts provided by manufacturers
to other purchasers subsequent to the sale of covered drugs
to covered entities are reported to the Secretary; and
``(II) appropriate credits and refunds are issued to
covered entities if such discounts or rebates have the effect
of lowering the applicable ceiling price for the relevant
quarter for the drugs involved.
``(v) Selective auditing of manufacturers and wholesalers
to ensure the integrity of the drug discount program under
this section.
``(vi) The imposition of sanctions in the form of civil
monetary penalties, which--
``(I) shall be assessed according to standards established
in regulations to be promulgated by the Secretary not later
than 180 days after the date of enactment of the Patient
Protection and Affordable Care Act;
``(II) shall not exceed $5,000 for each instance of
overcharging a covered entity that may have occurred; and
``(III) shall apply to any manufacturer with an agreement
under this section that knowingly and intentionally charges a
covered entity a price for purchase of a drug that exceeds
the maximum applicable price under subsection (a)(1).
``(2) Covered entity compliance.--
``(A) In general.--From amounts appropriated under
paragraph (4), the Secretary shall provide for improvements
in compliance by covered entities with the requirements of
this section in order to prevent diversion and violations of
the duplicate discount provision and other requirements
specified under subsection (a)(5).
``(B) Improvements.--The improvements described in
subparagraph (A) shall include the following:
``(i) The development of procedures to enable and require
covered entities to regularly update (at least annually) the
information on the Internet website of the Department of
Health and Human Services relating to this section.
``(ii) The development of a system for the Secretary to
verify the accuracy of information regarding covered entities
that is listed on the website described in clause (i).
``(iii) The development of more detailed guidance
describing methodologies and options available to covered
entities for billing covered drugs to State Medicaid agencies
in a manner that avoids duplicate discounts pursuant to
subsection (a)(5)(A).
``(iv) The establishment of a single, universal, and
standardized identification system by which each covered
entity site can be identified by manufacturers, distributors,
covered entities, and the Secretary for purposes of
facilitating the ordering, purchasing, and delivery of
covered drugs under this section, including the processing of
chargebacks for such drugs.
``(v) The imposition of sanctions, in appropriate cases as
determined by the Secretary, additional to those to which
covered entities are subject under subsection (a)(5)(E),
through one or more of the following actions:
``(I) Where a covered entity knowingly and intentionally
violates subsection (a)(5)(B), the covered entity shall be
required to pay a monetary penalty to a manufacturer or
manufacturers in the form of interest on sums for which the
covered entity is found liable under subsection (a)(5)(E),
such interest to be compounded monthly and equal to the
current short term interest rate as determined by the Federal
Reserve for the time period for which the covered entity is
liable.
``(II) Where the Secretary determines a violation of
subsection (a)(5)(B) was systematic and egregious as well as
knowing and intentional, removing the covered entity from the
drug discount program under this section and disqualifying
the entity from re-entry into such program for a reasonable
period of time to be determined by the Secretary.
``(III) Referring matters to appropriate Federal
authorities within the Food and Drug Administration, the
Office of Inspector General of Department of Health and Human
Services, or other Federal agencies for consideration of
appropriate action under other Federal statutes, such as the
Prescription Drug Marketing Act (21 U.S.C. 353).
``(3) Administrative dispute resolution process.--
``(A) In general.--Not later than 180 days after the date
of enactment of the Patient Protection and Affordable Care
Act, the Secretary shall promulgate regulations to establish
and implement an administrative process for the resolution of
claims by covered entities that they have been overcharged
for drugs purchased under this section, and claims by
manufacturers, after the conduct of audits as authorized by
subsection (a)(5)(D), of violations of subsections (a)(5)(A)
or (a)(5)(B), including appropriate procedures for the
provision of remedies and enforcement of determinations made
pursuant to such process through mechanisms and sanctions
described in paragraphs (1)(B) and (2)(B).
``(B) Deadlines and procedures.--Regulations promulgated by
the Secretary under subparagraph (A) shall--
``(i) designate or establish a decision-making official or
decision-making body within the Department of Health and
Human Services to be responsible for reviewing and finally
resolving claims by covered entities that they have been
charged prices for covered drugs in excess of the ceiling
price described in subsection (a)(1), and
[[Page H2102]]
claims by manufacturers that violations of subsection
(a)(5)(A) or (a)(5)(B) have occurred;
``(ii) establish such deadlines and procedures as may be
necessary to ensure that claims shall be resolved fairly,
efficiently, and expeditiously;
``(iii) establish procedures by which a covered entity may
discover and obtain such information and documents from
manufacturers and third parties as may be relevant to
demonstrate the merits of a claim that charges for a
manufacturer's product have exceeded the applicable ceiling
price under this section, and may submit such documents and
information to the administrative official or body
responsible for adjudicating such claim;
``(iv) require that a manufacturer conduct an audit of a
covered entity pursuant to subsection (a)(5)(D) as a
prerequisite to initiating administrative dispute resolution
proceedings against a covered entity;
``(v) permit the official or body designated under clause
(i), at the request of a manufacturer or manufacturers, to
consolidate claims brought by more than one manufacturer
against the same covered entity where, in the judgment of
such official or body, consolidation is appropriate and
consistent with the goals of fairness and economy of
resources; and
``(vi) include provisions and procedures to permit multiple
covered entities to jointly assert claims of overcharges by
the same manufacturer for the same drug or drugs in one
administrative proceeding, and permit such claims to be
asserted on behalf of covered entities by associations or
organizations representing the interests of such covered
entities and of which the covered entities are members.
``(C) Finality of administrative resolution.--The
administrative resolution of a claim or claims under the
regulations promulgated under subparagraph (A) shall be a
final agency decision and shall be binding upon the parties
involved, unless invalidated by an order of a court of
competent jurisdiction.
``(4) Authorization of appropriations.--There are
authorized to be appropriated to carry out this subsection,
such sums as may be necessary for fiscal year 2010 and each
succeeding fiscal year.''.
(b) Conforming Amendments.--Section 340B(a) of the Public
Health Service Act (42 U.S.C. 256b(a)) is amended--
(1) in subsection (a)(1), by adding at the end the
following: ``Each such agreement shall require that the
manufacturer furnish the Secretary with reports, on a
quarterly basis, of the price for each covered drug subject
to the agreement that, according to the manufacturer,
represents the maximum price that covered entities may
permissibly be required to pay for the drug (referred to in
this section as the `ceiling price'), and shall require that
the manufacturer offer each covered entity covered drugs for
purchase at or below the applicable ceiling price if such
drug is made available to any other purchaser at any
price.''; and
(2) in the first sentence of subsection (a)(5)(E), as
redesignated by section 7101(c), by inserting ``after audit
as described in subparagraph (D) and'' after ``finds,''.
SEC. 7103. GAO STUDY TO MAKE RECOMMENDATIONS ON IMPROVING THE
340B PROGRAM.
(a) Report.--Not later than 18 months after the date of
enactment of this Act, the Comptroller General of the United
States shall submit to Congress a report that examines
whether those individuals served by the covered entities
under the program under section 340B of the Public Health
Service Act (42 U.S.C. 256b) (referred to in this section as
the ``340B program'') are receiving optimal health care
services.
(b) Recommendations.--The report under subsection (a) shall
include recommendations on the following:
(1) Whether the 340B program should be expanded since it is
anticipated that the 47,000,000 individuals who are uninsured
as of the date of enactment of this Act will have health care
coverage once this Act is implemented.
(2) Whether mandatory sales of certain products by the 340B
program could hinder patients access to those therapies
through any provider.
(3) Whether income from the 340B program is being used by
the covered entities under the program to further the program
objectives.
TITLE VIII--CLASS ACT
SEC. 8001. SHORT TITLE OF TITLE.
This title may be cited as the ``Community Living
Assistance Services and Supports Act'' or the ``CLASS Act''.
SEC. 8002. ESTABLISHMENT OF NATIONAL VOLUNTARY INSURANCE
PROGRAM FOR PURCHASING COMMUNITY LIVING
ASSISTANCE SERVICES AND SUPPORT.
(a) Establishment of CLASS Program.--
(1) In general.--The Public Health Service Act (42 U.S.C.
201 et seq.), as amended by section 4302(a), is amended by
adding at the end the following:
``TITLE XXXII--COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS
``SEC. 3201. PURPOSE.
``The purpose of this title is to establish a national
voluntary insurance program for purchasing community living
assistance services and supports in order to--
``(1) provide individuals with functional limitations with
tools that will allow them to maintain their personal and
financial independence and live in the community through a
new financing strategy for community living assistance
services and supports;
``(2) establish an infrastructure that will help address
the Nation's community living assistance services and
supports needs;
``(3) alleviate burdens on family caregivers; and
``(4) address institutional bias by providing a financing
mechanism that supports personal choice and independence to
live in the community.
``SEC. 3202. DEFINITIONS.
``In this title:
``(1) Active enrollee.--The term `active enrollee' means an
individual who is enrolled in the CLASS program in accordance
with section 3204 and who has paid any premiums due to
maintain such enrollment.
``(2) Actively employed.--The term `actively employed'
means an individual who--
``(A) is reporting for work at the individual's usual place
of employment or at another location to which the individual
is required to travel because of the individual's employment
(or in the case of an individual who is a member of the
uniformed services, is on active duty and is physically able
to perform the duties of the individual's position); and
``(B) is able to perform all the usual and customary duties
of the individual's employment on the individual's regular
work schedule.
``(3) Activities of daily living.--The term `activities of
daily living' means each of the following activities
specified in section 7702B(c)(2)(B) of the Internal Revenue
Code of 1986:
``(A) Eating.
``(B) Toileting.
``(C) Transferring.
``(D) Bathing.
``(E) Dressing.
``(F) Continence.
``(4) CLASS program.--The term `CLASS program' means the
program established under this title.
``(5) Eligibility assessment system.--The term `Eligibility
Assessment System' means the entity established by the
Secretary under section 3205(a)(2) to make functional
eligibility determinations for the CLASS program.
``(6) Eligible beneficiary.--
``(A) In general.--The term `eligible beneficiary' means
any individual who is an active enrollee in the CLASS program
and, as of the date described in subparagraph (B)--
``(i) has paid premiums for enrollment in such program for
at least 60 months;
``(ii) has earned, with respect to at least 3 calendar
years that occur during the first 60 months for which the
individual has paid premiums for enrollment in the program,
at least an amount equal to the amount of wages and self-
employment income which an individual must have in order to
be credited with a quarter of coverage under section 213(d)
of the Social Security Act for the year; and
``(iii) has paid premiums for enrollment in such program
for at least 24 consecutive months, if a lapse in premium
payments of more than 3 months has occurred during the period
that begins on the date of the individual's enrollment and
ends on the date of such determination.
``(B) Date described.--For purposes of subparagraph (A),
the date described in this subparagraph is the date on which
the individual is determined to have a functional limitation
described in section 3203(a)(1)(C) that is expected to last
for a continuous period of more than 90 days.
``(C) Regulations.--The Secretary shall promulgate
regulations specifying exceptions to the minimum earnings
requirements under subparagraph (A)(ii) for purposes of being
considered an eligible beneficiary for certain populations.
``(7) Hospital; nursing facility; intermediate care
facility for the mentally retarded; institution for mental
diseases.--The terms `hospital', `nursing facility',
`intermediate care facility for the mentally retarded', and
`institution for mental diseases' have the meanings given
such terms for purposes of Medicaid.
``(8) CLASS independence advisory council.--The term `CLASS
Independence Advisory Council' or `Council' means the
Advisory Council established under section 3207 to advise the
Secretary.
``(9) CLASS independence benefit plan.--The term `CLASS
Independence Benefit Plan' means the benefit plan developed
and designated by the Secretary in accordance with section
3203.
``(10) CLASS independence fund.--The term `CLASS
Independence Fund' or `Fund' means the fund established under
section 3206.
``(11) Medicaid.--The term `Medicaid' means the program
established under title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).
``(12) Poverty line.--The term `poverty line' has the
meaning given that term in section 2110(c)(5) of the Social
Security Act (42 U.S.C. 1397jj(c)(5)).
``(13) Protection and advocacy system.--The term
`Protection and Advocacy System' means the system for each
State established under section 143 of the Developmental
Disabilities Assistance and Bill of Rights Act of 2000 (42
U.S.C. 15043).
``SEC. 3203. CLASS INDEPENDENCE BENEFIT PLAN.
``(a) Process for Development.--
``(1) In general.--The Secretary, in consultation with
appropriate actuaries and other experts, shall develop at
least 3 actuarially sound benefit plans as alternatives for
consideration for designation by the Secretary as the CLASS
Independence Benefit Plan under which eligible beneficiaries
shall receive benefits under this title. Each of the plan
alternatives developed shall be designed to provide eligible
beneficiaries with the benefits described in section 3205
consistent with the following requirements:
``(A) Premiums.--
``(i) In general.--Beginning with the first year of the
CLASS program, and for each year thereafter, subject to
clauses (ii) and (iii), the Secretary shall establish all
premiums to be paid by enrollees for the year based on an
actuarial analysis of the 75-year costs of the program that
ensures solvency throughout such 75-year period.
[[Page H2103]]
``(ii) Nominal premium for poorest individuals and full-
time students.--
``(I) In general.--The monthly premium for enrollment in
the CLASS program shall not exceed the applicable dollar
amount per month determined under subclause (II) for--
``(aa) any individual whose income does not exceed the
poverty line; and
``(bb) any individual who has not attained age 22, and is
actively employed during any period in which the individual
is a full-time student (as determined by the Secretary).
``(II) Applicable dollar amount.--The applicable dollar
amount described in this subclause is the amount equal to $5,
increased by the percentage increase in the consumer price
index for all urban consumers (U.S. city average) for each
year occurring after 2009 and before such year.
``(iii) Class independence fund reserves.--At such time as
the CLASS program has been in operation for 10 years, the
Secretary shall establish all premiums to be paid by
enrollees for the year based on an actuarial analysis that
accumulated reserves in the CLASS Independence Fund would not
decrease in that year. At such time as the Secretary
determines the CLASS program demonstrates a sustained ability
to finance expected yearly expenses with expected yearly
premiums and interest credited to the CLASS Independence
Fund, the Secretary may decrease the required amount of CLASS
Independence Fund reserves.
``(B) Vesting period.--A 5-year vesting period for
eligibility for benefits.
``(C) Benefit triggers.--A benefit trigger for provision of
benefits that requires a determination that an individual has
a functional limitation, as certified by a licensed health
care practitioner, described in any of the following clauses
that is expected to last for a continuous period of more than
90 days:
``(i) The individual is determined to be unable to perform
at least the minimum number (which may be 2 or 3) of
activities of daily living as are required under the plan for
the provision of benefits without substantial assistance (as
defined by the Secretary) from another individual.
``(ii) The individual requires substantial supervision to
protect the individual from threats to health and safety due
to substantial cognitive impairment.
``(iii) The individual has a level of functional limitation
similar (as determined under regulations prescribed by the
Secretary) to the level of functional limitation described in
clause (i) or (ii).
``(D) Cash benefit.--Payment of a cash benefit that
satisfies the following requirements:
``(i) Minimum required amount.--The benefit amount provides
an eligible beneficiary with not less than an average of $50
per day (as determined based on the reasonably expected
distribution of beneficiaries receiving benefits at various
benefit levels).
``(ii) Amount scaled to functional ability.--The benefit
amount is varied based on a scale of functional ability, with
not less than 2, and not more than 6, benefit level amounts.
``(iii) Daily or weekly.--The benefit is paid on a daily or
weekly basis.
``(iv) No lifetime or aggregate limit.--The benefit is not
subject to any lifetime or aggregate limit.
``(E) Coordination with supplemental coverage obtained
through the exchange.--The benefits allow for coordination
with any supplemental coverage purchased through an Exchange
established under section 1311 of the Patient Protection and
Affordable Care Act.
``(2) Review and recommendation by the class independence
advisory council.--The CLASS Independence Advisory Council
shall--
``(A) evaluate the alternative benefit plans developed
under paragraph (1); and
``(B) recommend for designation as the CLASS Independence
Benefit Plan for offering to the public the plan that the
Council determines best balances price and benefits to meet
enrollees' needs in an actuarially sound manner, while
optimizing the probability of the long-term sustainability of
the CLASS program.
``(3) Designation by the secretary.--Not later than October
1, 2012, the Secretary, taking into consideration the
recommendation of the CLASS Independence Advisory Council
under paragraph (2)(B), shall designate a benefit plan as the
CLASS Independence Benefit Plan. The Secretary shall publish
such designation, along with details of the plan and the
reasons for the selection by the Secretary, in a final rule
that allows for a period of public comment.
``(b) Additional Premium Requirements.--
``(1) Adjustment of premiums.--
``(A) In general.--Except as provided in subparagraphs (B),
(C), (D), and (E), the amount of the monthly premium
determined for an individual upon such individual's
enrollment in the CLASS program shall remain the same for as
long as the individual is an active enrollee in the program.
``(B) Recalculated premium if required for program
solvency.--
``(i) In general.--Subject to clause (ii), if the Secretary
determines, based on the most recent report of the Board of
Trustees of the CLASS Independence Fund, the advice of the
CLASS Independence Advisory Council, and the annual report of
the Inspector General of the Department of Health and Human
Services, and waste, fraud, and abuse, or such other
information as the Secretary determines appropriate, that the
monthly premiums and income to the CLASS Independence Fund
for a year are projected to be insufficient with respect to
the 20-year period that begins with that year, the Secretary
shall adjust the monthly premiums for individuals enrolled in
the CLASS program as necessary (but maintaining a nominal
premium for enrollees whose income is below the poverty line
or who are full-time students actively employed).
``(ii) Exemption from increase.--Any increase in a monthly
premium imposed as result of a determination described in
clause (i) shall not apply with respect to the monthly
premium of any active enrollee who--
``(I) has attained age 65;
``(II) has paid premiums for enrollment in the program for
at least 20 years; and
``(III) is not actively employed.
``(C) Recalculated premium if reenrollment after more than
a 3-month lapse.--
``(i) In general.--The reenrollment of an individual after
a 90-day period during which the individual failed to pay the
monthly premium required to maintain the individual's
enrollment in the CLASS program shall be treated as an
initial enrollment for purposes of age-adjusting the premium
for enrollment in the program.
``(ii) Credit for prior months if reenrolled within 5
years.--An individual who reenrolls in the CLASS program
after such a 90-day period and before the end of the 5-year
period that begins with the first month for which the
individual failed to pay the monthly premium required to
maintain the individual's enrollment in the program shall
be--
``(I) credited with any months of paid premiums that
accrued prior to the individual's lapse in enrollment; and
``(II) notwithstanding the total amount of any such
credited months, required to satisfy section 3202(6)(A)(ii)
before being eligible to receive benefits.
``(D) No longer status as a full-time student.--An
individual subject to a nominal premium on the basis of being
described in subsection (a)(1)(A)(ii)(I)(bb) who ceases to be
described in that subsection, beginning with the first month
following the month in which the individual ceases to be so
described, shall be subject to the same monthly premium as
the monthly premium that applies to an individual of the same
age who first enrolls in the program under the most similar
circumstances as the individual (such as the first year of
eligibility for enrollment in the program or in a subsequent
year).
``(E) Penalty for reenollment after 5-year lapse.--In the
case of an individual who reenrolls in the CLASS program
after the end of the 5-year period described in subparagraph
(C)(ii), the monthly premium required for the individual
shall be the age-adjusted premium that would be applicable to
an initially enrolling individual who is the same age as the
reenrolling individual, increased by the greater of--
``(i) an amount that the Secretary determines is
actuarially sound for each month that occurs during the
period that begins with the first month for which the
individual failed to pay the monthly premium required to
maintain the individual's enrollment in the CLASS program and
ends with the month preceding the month in which the
reenollment is effective; or
``(ii) 1 percent of the applicable age-adjusted premium for
each such month occurring in such period.
``(2) Administrative expenses.--In determining the monthly
premiums for the CLASS program the Secretary may factor in
costs for administering the program, not to exceed for any
year in which the program is in effect under this title, an
amount equal to 3 percent of all premiums paid during the
year.
``(3) No underwriting requirements.--No underwriting (other
than on the basis of age in accordance with subparagraphs (D)
and (E) of paragraph (1)) shall be used to--
``(A) determine the monthly premium for enrollment in the
CLASS program; or
``(B) prevent an individual from enrolling in the program.
``(c) Self-attestation and Verification of Income.--The
Secretary shall establish procedures to--
``(1) permit an individual who is eligible for the nominal
premium required under subsection (a)(1)(A)(ii), as part of
their automatic enrollment in the CLASS program, to self-
attest that their income does not exceed the poverty line or
that their status as a full-time student who is actively
employed;
``(2) verify, using procedures similar to the procedures
used by the Commissioner of Social Security under section
1631(e)(1)(B)(ii) of the Social Security Act and consistent
with the requirements applicable to the conveyance of data
and information under section 1942 of such Act, the validity
of such self-attestation; and
``(3) require an individual to confirm, on at least an
annual basis, that their income does not exceed the poverty
line or that they continue to maintain such status.
``SEC. 3204. ENROLLMENT AND DISENROLLMENT REQUIREMENTS.
``(a) Automatic Enrollment.--
``(1) In general.--Subject to paragraph (2), the Secretary,
in coordination with the Secretary of the Treasury, shall
establish procedures under which each individual described in
subsection (c) may be automatically enrolled in the CLASS
program by an employer of such individual in the same manner
as an employer may elect to automatically enroll employees in
a plan under section 401(k), 403(b), or 457 of the Internal
Revenue Code of 1986.
``(2) Alternative enrollment procedures.--The procedures
established under paragraph (1) shall provide for an
alternative enrollment process for an individual described in
subsection (c) in the case of such an individual--
``(A) who is self-employed;
``(B) who has more than 1 employer; or
``(C) whose employer does not elect to participate in the
automatic enrollment process established by the Secretary.
``(3) Administration.--
``(A) In general.--The Secretary and the Secretary of the
Treasury shall, by regulation, establish procedures to ensure
that an individual is not automatically enrolled in the CLASS
program by more than 1 employer.
[[Page H2104]]
``(B) Form.--Enrollment in the CLASS program shall be made
in such manner as the Secretary may prescribe in order to
ensure ease of administration.
``(b) Election to Opt-Out.--An individual described in
subsection (c) may elect to waive enrollment in the CLASS
program at any time in such form and manner as the Secretary
and the Secretary of the Treasury shall prescribe.
``(c) Individual Described.--For purposes of enrolling in
the CLASS program, an individual described in this paragraph
is an individual--
``(1) who has attained age 18;
``(2) who--
``(A) receives wages on which there is imposed a tax under
section 3201(a) of the Internal Revenue Code of 1986; or
``(B) derives self-employment income on which there is
imposed a tax under section 1401(a) of the Internal Revenue
Code of 1986;
``(3) who is actively employed; and
``(4) who is not--
``(A) a patient in a hospital or nursing facility, an
intermediate care facility for the mentally retarded, or an
institution for mental diseases and receiving medical
assistance under Medicaid; or
``(B) confined in a jail, prison, other penal institution
or correctional facility, or by court order pursuant to
conviction of a criminal offense or in connection with a
verdict or finding described in section 202(x)(1)(A)(ii) of
the Social Security Act (42 U.S.C. 402(x)(1)(A)(ii)).
``(d) Rule of Construction.--Nothing in this title shall be
construed as requiring an active enrollee to continue to
satisfy subparagraph (B) or (C) of subsection (c)(1) in order
to maintain enrollment in the CLASS program.
``(e) Payment.--
``(1) Payroll deduction.--An amount equal to the monthly
premium for the enrollment in the CLASS program of an
individual shall be deducted from the wages or self-
employment income of such individual in accordance with such
procedures as the Secretary, in coordination with the
Secretary of the Treasury, shall establish for employers who
elect to deduct and withhold such premiums on behalf of
enrolled employees.
``(2) Alternative payment mechanism.--The Secretary, in
coordination with the Secretary of the Treasury, shall
establish alternative procedures for the payment of monthly
premiums by an individual enrolled in the CLASS program--
``(A) who does not have an employer who elects to deduct
and withhold premiums in accordance with subparagraph (A); or
``(B) who does not earn wages or derive self-employment
income.
``(f) Transfer of Premiums Collected.--
``(1) In general.--During each calendar year the Secretary
of the Treasury shall deposit into the CLASS Independence
Fund a total amount equal, in the aggregate, to 100 percent
of the premiums collected during that year.
``(2) Transfers based on estimates.--The amount deposited
pursuant to paragraph (1) shall be transferred in at least
monthly payments to the CLASS Independence Fund on the basis
of estimates by the Secretary and certified to the Secretary
of the Treasury of the amounts collected in accordance with
subparagraphs (A) and (B) of paragraph (5). Proper
adjustments shall be made in amounts subsequently transferred
to the Fund to the extent prior estimates were in excess of,
or were less than, actual amounts collected.
``(g) Other Enrollment and Disenrollment Opportunities.--
The Secretary, in coordination with the Secretary of the
Treasury, shall establish procedures under which--
``(1) an individual who, in the year of the individual's
initial eligibility to enroll in the CLASS program, has
elected to waive enrollment in the program, is eligible to
elect to enroll in the program, in such form and manner as
the Secretaries shall establish, only during an open
enrollment period established by the Secretaries that is
specific to the individual and that may not occur more
frequently than biennially after the date on which the
individual first elected to waive enrollment in the program;
and
``(2) an individual shall only be permitted to disenroll
from the program (other than for nonpayment of premiums)
during an annual disenrollment period established by the
Secretaries and in such form and manner as the Secretaries
shall establish.
``SEC. 3205. BENEFITS.
``(a) Determination of Eligibility.--
``(1) Application for receipt of benefits.--The Secretary
shall establish procedures under which an active enrollee
shall apply for receipt of benefits under the CLASS
Independence Benefit Plan.
``(2) Eligibility assessments.--
``(A) In general.--Not later than January 1, 2012, the
Secretary shall--
``(i) establish an Eligibility Assessment System (other
than a service with which the Commissioner of Social Security
has entered into an agreement, with respect to any State, to
make disability determinations for purposes of title II or
XVI of the Social Security Act) to provide for eligibility
assessments of active enrollees who apply for receipt of
benefits;
``(ii) enter into an agreement with the Protection and
Advocacy System for each State to provide advocacy services
in accordance with subsection (d); and
``(iii) enter into an agreement with public and private
entities to provide advice and assistance counseling in
accordance with subsection (e).
``(B) Regulations.--The Secretary shall promulgate
regulations to develop an expedited nationally equitable
eligibility determination process, as certified by a licensed
health care practitioner, an appeals process, and a
redetermination process, as certified by a licensed health
care practitioner, including whether an active enrollee is
eligible for a cash benefit under the program and if so, the
amount of the cash benefit (in accordance the sliding scale
established under the plan).
``(C) Presumptive eligibility for certain institutionalized
enrollees planning to discharge.--An active enrollee shall be
deemed presumptively eligible if the enrollee--
``(i) has applied for, and attests is eligible for, the
maximum cash benefit available under the sliding scale
established under the CLASS Independence Benefit Plan;
``(ii) is a patient in a hospital (but only if the
hospitalization is for long-term care), nursing facility,
intermediate care facility for the mentally retarded, or an
institution for mental diseases; and
``(iii) is in the process of, or about to begin the process
of, planning to discharge from the hospital, facility, or
institution, or within 60 days from the date of discharge
from the hospital, facility, or institution.
``(D) Appeals.--The Secretary shall establish procedures
under which an applicant for benefits under the CLASS
Independence Benefit Plan shall be guaranteed the right to
appeal an adverse determination.
``(b) Benefits.--An eligible beneficiary shall receive the
following benefits under the CLASS Independence Benefit Plan:
``(1) Cash benefit.--A cash benefit established by the
Secretary in accordance with the requirements of section
3203(a)(1)(D) that--
``(A) the first year in which beneficiaries receive the
benefits under the plan, is not less than the average dollar
amount specified in clause (i) of such section; and
``(B) for any subsequent year, is not less than the average
per day dollar limit applicable under this subparagraph for
the preceding year, increased by the percentage increase in
the consumer price index for all urban consumers (U.S. city
average) over the previous year.
``(2) Advocacy services.--Advocacy services in accordance
with subsection (d).
``(3) Advice and assistance counseling.--Advice and
assistance counseling in accordance with subsection (e).
``(4) Administrative expenses.--Advocacy services and
advise and assistance counseling services under paragraphs
(2) and (3) of this subsection shall be included as
administrative expenses under section 3203(b)(3).
``(c) Payment of Benefits.--
``(1) Life independence account.--
``(A) In general.--The Secretary shall establish procedures
for administering the provision of benefits to eligible
beneficiaries under the CLASS Independence Benefit Plan,
including the payment of the cash benefit for the beneficiary
into a Life Independence Account established by the Secretary
on behalf of each eligible beneficiary.
``(B) Use of cash benefits.--Cash benefits paid into a Life
Independence Account of an eligible beneficiary shall be used
to purchase nonmedical services and supports that the
beneficiary needs to maintain his or her independence at home
or in another residential setting of their choice in the
community, including (but not limited to) home modifications,
assistive technology, accessible transportation, homemaker
services, respite care, personal assistance services, home
care aides, and nursing support. Nothing in the preceding
sentence shall prevent an eligible beneficiary from using
cash benefits paid into a Life Independence Account for
obtaining assistance with decision making concerning medical
care, including the right to accept or refuse medical or
surgical treatment and the right to formulate advance
directives or other written instructions recognized under
State law, such as a living will or durable power of attorney
for health care, in the case that an injury or illness causes
the individual to be unable to make health care decisions.
``(C) Electronic management of funds.--The Secretary shall
establish procedures for--
``(i) crediting an account established on behalf of a
beneficiary with the beneficiary's cash daily benefit;
``(ii) allowing the beneficiary to access such account
through debit cards; and
``(iii) accounting for withdrawals by the beneficiary from
such account.
``(D) Primary payor rules for beneficiaries who are
enrolled in medicaid.--In the case of an eligible beneficiary
who is enrolled in Medicaid, the following payment rules
shall apply:
``(i) Institutionalized beneficiary.--If the beneficiary is
a patient in a hospital, nursing facility, intermediate care
facility for the mentally retarded, or an institution for
mental diseases, the beneficiary shall retain an amount equal
to 5 percent of the beneficiary's daily or weekly cash
benefit (as applicable) (which shall be in addition to the
amount of the beneficiary's personal needs allowance provided
under Medicaid), and the remainder of such benefit shall be
applied toward the facility's cost of providing the
beneficiary's care, and Medicaid shall provide secondary
coverage for such care.
``(ii) Beneficiaries receiving home and community-based
services.--
``(I) 50 percent of benefit retained by beneficiary.--
Subject to subclause (II), if a beneficiary is receiving
medical assistance under Medicaid for home and community
based services, the beneficiary shall retain an amount equal
to 50 percent of the beneficiary's daily or weekly cash
benefit (as applicable), and the remainder of the daily or
weekly cash benefit shall be applied toward the cost to the
State of providing such assistance (and shall not be used to
claim Federal matching funds under Medicaid), and Medicaid
shall provide secondary coverage for the remainder of any
costs incurred in providing such assistance.
[[Page H2105]]
``(II) Requirement for state offset.--A State shall be paid
the remainder of a beneficiary's daily or weekly cash benefit
under subclause (I) only if the State home and community-
based waiver under section 1115 of the Social Security Act
(42 U.S.C. 1315) or subsection (c) or (d) of section 1915 of
such Act (42 U.S.C. 1396n), or the State plan amendment under
subsection (i) of such section does not include a waiver of
the requirements of section 1902(a)(1) of the Social Security
Act (relating to statewideness) or of section 1902(a)(10)(B)
of such Act (relating to comparability) and the State offers
at a minimum case management services, personal care
services, habilitation services, and respite care under such
a waiver or State plan amendment.
``(III) Definition of home and community-based services.--
In this clause, the term `home and community-based services'
means any services which may be offered under a home and
community-based waiver authorized for a State under section
1115 of the Social Security Act (42 U.S.C. 1315) or
subsection (c) or (d) of section 1915 of such Act (42 U.S.C.
1396n) or under a State plan amendment under subsection (i)
of such section.
``(iii) Beneficiaries enrolled in programs of all-inclusive
care for the elderly (pace).--
``(I) In general.--Subject to subclause (II), if a
beneficiary is receiving medical assistance under Medicaid
for PACE program services under section 1934 of the Social
Security Act (42 U.S.C. 1396u-4), the beneficiary shall
retain an amount equal to 50 percent of the beneficiary's
daily or weekly cash benefit (as applicable), and the
remainder of the daily or weekly cash benefit shall be
applied toward the cost to the State of providing such
assistance (and shall not be used to claim Federal matching
funds under Medicaid), and Medicaid shall provide secondary
coverage for the remainder of any costs incurred in providing
such assistance.
``(II) Institutionalized recipients of pace program
services.--If a beneficiary receiving assistance under
Medicaid for PACE program services is a patient in a
hospital, nursing facility, intermediate care facility for
the mentally retarded, or an institution for mental diseases,
the beneficiary shall be treated as in institutionalized
beneficiary under clause (i).
``(2) Authorized representatives.--
``(A) In general.--The Secretary shall establish procedures
to allow access to a beneficiary's cash benefits by an
authorized representative of the eligible beneficiary on
whose behalf such benefits are paid.
``(B) Quality assurance and protection against fraud and
abuse.--The procedures established under subparagraph (A)
shall ensure that authorized representatives of eligible
beneficiaries comply with standards of conduct established by
the Secretary, including standards requiring that such
representatives provide quality services on behalf of such
beneficiaries, do not have conflicts of interest, and do not
misuse benefits paid on behalf of such beneficiaries or
otherwise engage in fraud or abuse.
``(3) Commencement of benefits.--Benefits shall be paid to,
or on behalf of, an eligible beneficiary beginning with the
first month in which an application for such benefits is
approved.
``(4) Rollover option for lump-sum payment.--An eligible
beneficiary may elect to--
``(A) defer payment of their daily or weekly benefit and to
rollover any such deferred benefits from month-to-month, but
not from year-to-year; and
``(B) receive a lump-sum payment of such deferred benefits
in an amount that may not exceed the lesser of--
``(i) the total amount of the accrued deferred benefits; or
``(ii) the applicable annual benefit.
``(5) Period for determination of annual benefits.--
``(A) In general.--The applicable period for determining
with respect to an eligible beneficiary the applicable annual
benefit and the amount of any accrued deferred benefits is
the 12-month period that commences with the first month in
which the beneficiary began to receive such benefits, and
each 12-month period thereafter.
``(B) Inclusion of increased benefits.--The Secretary shall
establish procedures under which cash benefits paid to an
eligible beneficiary that increase or decrease as a result of
a change in the functional status of the beneficiary before
the end of a 12-month benefit period shall be included in the
determination of the applicable annual benefit paid to the
eligible beneficiary.
``(C) Recoupment of unpaid, accrued benefits.--
``(i) In general.--The Secretary, in coordination with the
Secretary of the Treasury, shall recoup any accrued benefits
in the event of--
``(I) the death of a beneficiary; or
``(II) the failure of a beneficiary to elect under
paragraph (4)(B) to receive such benefits as a lump-sum
payment before the end of the 12-month period in which such
benefits accrued.
``(ii) Payment into class independence fund.--Any benefits
recouped in accordance with clause (i) shall be paid into the
CLASS Independence Fund and used in accordance with section
3206.
``(6) Requirement to recertify eligibility for receipt of
benefits.--An eligible beneficiary shall periodically, as
determined by the Secretary--
``(A) recertify by submission of medical evidence the
beneficiary's continued eligibility for receipt of benefits;
and
``(B) submit records of expenditures attributable to the
aggregate cash benefit received by the beneficiary during the
preceding year.
``(7) Supplement, not supplant other health care
benefits.--Subject to the Medicaid payment rules under
paragraph (1)(D), benefits received by an eligible
beneficiary shall supplement, but not supplant, other health
care benefits for which the beneficiary is eligible under
Medicaid or any other Federally funded program that provides
health care benefits or assistance.
``(d) Advocacy Services.--An agreement entered into under
subsection (a)(2)(A)(ii) shall require the Protection and
Advocacy System for the State to--
``(1) assign, as needed, an advocacy counselor to each
eligible beneficiary that is covered by such agreement and
who shall provide an eligible beneficiary with--
``(A) information regarding how to access the appeals
process established for the program;
``(B) assistance with respect to the annual recertification
and notification required under subsection (c)(6); and
``(C) such other assistance with obtaining services as the
Secretary, by regulation, shall require; and
``(2) ensure that the System and such counselors comply
with the requirements of subsection (h).
``(e) Advice and Assistance Counseling.--An agreement
entered into under subsection (a)(2)(A)(iii) shall require
the entity to assign, as requested by an eligible beneficiary
that is covered by such agreement, an advice and assistance
counselor who shall provide an eligible beneficiary with
information regarding--
``(1) accessing and coordinating long-term services and
supports in the most integrated setting;
``(2) possible eligibility for other benefits and services;
``(3) development of a service and support plan;
``(4) information about programs established under the
Assistive Technology Act of 1998 and the services offered
under such programs;
``(5) available assistance with decision making concerning
medical care, including the right to accept or refuse medical
or surgical treatment and the right to formulate advance
directives or other written instructions recognized under
State law, such as a living will or durable power of attorney
for health care, in the case that an injury or illness causes
the individual to be unable to make health care decisions;
and
``(6) such other services as the Secretary, by regulation,
may require.
``(f) No Effect on Eligibility for Other Benefits.--
Benefits paid to an eligible beneficiary under the CLASS
program shall be disregarded for purposes of determining or
continuing the beneficiary's eligibility for receipt of
benefits under any other Federal, State, or locally funded
assistance program, including benefits paid under titles II,
XVI, XVIII, XIX, or XXI of the Social Security Act (42 U.S.C.
401 et seq., 1381 et seq., 1395 et seq., 1396 et seq., 1397aa
et seq.), under the laws administered by the Secretary of
Veterans Affairs, under low-income housing assistance
programs, or under the supplemental nutrition assistance
program established under the Food and Nutrition Act of 2008
(7 U.S.C. 2011 et seq.).
``(g) Rule of Construction.--Nothing in this title shall be
construed as prohibiting benefits paid under the CLASS
Independence Benefit Plan from being used to compensate a
family caregiver for providing community living assistance
services and supports to an eligible beneficiary.
``(h) Protection Against Conflict of Interests.--The
Secretary shall establish procedures to ensure that the
Eligibility Assessment System, the Protection and Advocacy
System for a State, advocacy counselors for eligible
beneficiaries, and any other entities that provide services
to active enrollees and eligible beneficiaries under the
CLASS program comply with the following:
``(1) If the entity provides counseling or planning
services, such services are provided in a manner that fosters
the best interests of the active enrollee or beneficiary.
``(2) The entity has established operating procedures that
are designed to avoid or minimize conflicts of interest
between the entity and an active enrollee or beneficiary.
``(3) The entity provides information about all services
and options available to the active enrollee or beneficiary,
to the best of its knowledge, including services available
through other entities or providers.
``(4) The entity assists the active enrollee or beneficiary
to access desired services, regardless of the provider.
``(5) The entity reports the number of active enrollees and
beneficiaries provided with assistance by age, disability,
and whether such enrollees and beneficiaries received
services from the entity or another entity.
``(6) If the entity provides counseling or planning
services, the entity ensures that an active enrollee or
beneficiary is informed of any financial interest that the
entity has in a service provider.
``(7) The entity provides an active enrollee or beneficiary
with a list of available service providers that can meet the
needs of the active enrollee or beneficiary.
``SEC. 3206. CLASS INDEPENDENCE FUND.
``(a) Establishment of CLASS Independence Fund.--There is
established in the Treasury of the United States a trust fund
to be known as the `CLASS Independence Fund'. The Secretary
of the Treasury shall serve as Managing Trustee of such Fund.
The Fund shall consist of all amounts derived from payments
into the Fund under sections 3204(f) and 3205(c)(5)(C)(ii),
and remaining after investment of such amounts under
subsection (b), including additional amounts derived as
income from such investments. The amounts held in the Fund
are appropriated and shall remain available without fiscal
year limitation--
``(1) to be held for investment on behalf of individuals
enrolled in the CLASS program;
[[Page H2106]]
``(2) to pay the administrative expenses related to the
Fund and to investment under subsection (b); and
``(3) to pay cash benefits to eligible beneficiaries under
the CLASS Independence Benefit Plan.
``(b) Investment of Fund Balance.--The Secretary of the
Treasury shall invest and manage the CLASS Independence Fund
in the same manner, and to the same extent, as the Federal
Supplementary Medical Insurance Trust Fund may be invested
and managed under subsections (c), (d), and (e) of section
1841(d) of the Social Security Act (42 U.S.C. 1395t).
``(c) Board of Trustees.--
``(1) In general.--With respect to the CLASS Independence
Fund, there is hereby created a body to be known as the Board
of Trustees of the CLASS Independence Fund (hereinafter in
this section referred to as the `Board of Trustees') composed
of the Secretary of the Treasury, the Secretary of Labor, and
the Secretary of Health and Human Services, all ex officio,
and of two members of the public (both of whom may not be
from the same political party), who shall be nominated by the
President for a term of 4 years and subject to confirmation
by the Senate. A member of the Board of Trustees serving as a
member of the public and nominated and confirmed to fill a
vacancy occurring during a term shall be nominated and
confirmed only for the remainder of such term. An individual
nominated and confirmed as a member of the public may serve
in such position after the expiration of such member's term
until the earlier of the time at which the member's successor
takes office or the time at which a report of the Board is
first issued under paragraph (2) after the expiration of the
member's term. The Secretary of the Treasury shall be the
Managing Trustee of the Board of Trustees. The Board of
Trustees shall meet not less frequently than once each
calendar year. A person serving on the Board of Trustees
shall not be considered to be a fiduciary and shall not be
personally liable for actions taken in such capacity with
respect to the Trust Fund.
``(2) Duties.--
``(A) In general.--It shall be the duty of the Board of
Trustees to do the following:
``(i) Hold the CLASS Independence Fund.
``(ii) Report to the Congress not later than the first day
of April of each year on the operation and status of the
CLASS Independence Fund during the preceding fiscal year and
on its expected operation and status during the current
fiscal year and the next 2 fiscal years.
``(iii) Report immediately to the Congress whenever the
Board is of the opinion that the amount of the CLASS
Independence Fund is not actuarially sound in regards to the
projection under section 3203(b)(1)(B)(i).
``(iv) Review the general policies followed in managing the
CLASS Independence Fund, and recommend changes in such
policies, including necessary changes in the provisions of
law which govern the way in which the CLASS Independence Fund
is to be managed.
``(B) Report.--The report provided for in subparagraph
(A)(ii) shall--
``(i) include--
``(I) a statement of the assets of, and the disbursements
made from, the CLASS Independence Fund during the preceding
fiscal year;
``(II) an estimate of the expected income to, and
disbursements to be made from, the CLASS Independence Fund
during the current fiscal year and each of the next 2 fiscal
years;
``(III) a statement of the actuarial status of the CLASS
Independence Fund for the current fiscal year, each of the
next 2 fiscal years, and as projected over the 75-year period
beginning with the current fiscal year; and
``(IV) an actuarial opinion by the Chief Actuary of the
Centers for Medicare & Medicaid Services certifying that the
techniques and methodologies used are generally accepted
within the actuarial profession and that the assumptions and
cost estimates used are reasonable; and
``(ii) be printed as a House document of the session of the
Congress to which the report is made.
``(C) Recommendations.--If the Board of Trustees determines
that enrollment trends and expected future benefit claims on
the CLASS Independence Fund are not actuarially sound in
regards to the projection under section 3203(b)(1)(B)(i) and
are unlikely to be resolved with reasonable premium increases
or through other means, the Board of Trustees shall include
in the report provided for in subparagraph (A)(ii)
recommendations for such legislative action as the Board of
Trustees determine to be appropriate, including whether to
adjust monthly premiums or impose a temporary moratorium on
new enrollments.
``SEC. 3207. CLASS INDEPENDENCE ADVISORY COUNCIL.
``(a) Establishment.--There is hereby created an Advisory
Committee to be known as the `CLASS Independence Advisory
Council'.
``(b) Membership.--
``(1) In general.--The CLASS Independence Advisory Council
shall be composed of not more than 15 individuals, not
otherwise in the employ of the United States--
``(A) who shall be appointed by the President without
regard to the civil service laws and regulations; and
``(B) a majority of whom shall be representatives of
individuals who participate or are likely to participate in
the CLASS program, and shall include representatives of older
and younger workers, individuals with disabilities, family
caregivers of individuals who require services and supports
to maintain their independence at home or in another
residential setting of their choice in the community,
individuals with expertise in long-term care or disability
insurance, actuarial science, economics, and other relevant
disciplines, as determined by the Secretary.
``(2) Terms.--
``(A) In general.--The members of the CLASS Independence
Advisory Council shall serve overlapping terms of 3 years
(unless appointed to fill a vacancy occurring prior to the
expiration of a term, in which case the individual shall
serve for the remainder of the term).
``(B) Limitation.--A member shall not be eligible to serve
for more than 2 consecutive terms.
``(3) Chair.--The President shall, from time to time,
appoint one of the members of the CLASS Independence Advisory
Council to serve as the Chair.
``(c) Duties.--The CLASS Independence Advisory Council
shall advise the Secretary on matters of general policy in
the administration of the CLASS program established under
this title and in the formulation of regulations under this
title including with respect to--
``(1) the development of the CLASS Independence Benefit
Plan under section 3203;
``(2) the determination of monthly premiums under such
plan; and
``(3) the financial solvency of the program.
``(d) Application of FACA.--The Federal Advisory Committee
Act (5 U.S.C. App.), other than section 14 of that Act, shall
apply to the CLASS Independence Advisory Council.
``(e) Authorization of Appropriations.--
``(1) In general.--There are authorized to be appropriated
to the CLASS Independence Advisory Council to carry out its
duties under this section, such sums as may be necessary for
fiscal year 2011 and for each fiscal year thereafter.
``(2) Availability.--Any sums appropriated under the
authorization contained in this section shall remain
available, without fiscal year limitation, until expended.
``SEC. 3208. SOLVENCY AND FISCAL INDEPENDENCE; REGULATIONS;
ANNUAL REPORT.
``(a) Solvency.--The Secretary shall regularly consult with
the Board of Trustees of the CLASS Independence Fund and the
CLASS Independence Advisory Council, for purposes of ensuring
that enrollees premiums are adequate to ensure the financial
solvency of the CLASS program, both with respect to fiscal
years occurring in the near-term and fiscal years occurring
over 20- and 75-year periods, taking into account the
projections required for such periods under subsections
(a)(1)(A)(i) and (b)(1)(B)(i) of section 3202.
``(b) No Taxpayer Funds Used To Pay Benefits.--No taxpayer
funds shall be used for payment of benefits under a CLASS
Independent Benefit Plan. For purposes of this subsection,
the term `taxpayer funds' means any Federal funds from a
source other than premiums deposited by CLASS program
participants in the CLASS Independence Fund and any
associated interest earnings.
``(c) Regulations.--The Secretary shall promulgate such
regulations as are necessary to carry out the CLASS program
in accordance with this title. Such regulations shall include
provisions to prevent fraud and abuse under the program.
``(d) Annual Report.--Beginning January 1, 2014, the
Secretary shall submit an annual report to Congress on the
CLASS program. Each report shall include the following:
``(1) The total number of enrollees in the program.
``(2) The total number of eligible beneficiaries during the
fiscal year.
``(3) The total amount of cash benefits provided during the
fiscal year.
``(4) A description of instances of fraud or abuse
identified during the fiscal year.
``(5) Recommendations for such administrative or
legislative action as the Secretary determines is necessary
to improve the program, ensure the solvency of the program,
or to prevent the occurrence of fraud or abuse.
``SEC. 3209. INSPECTOR GENERAL'S REPORT.
``The Inspector General of the Department of Health and
Human Services shall submit an annual report to the Secretary
and Congress relating to the overall progress of the CLASS
program and of the existence of waste, fraud, and abuse in
the CLASS program. Each such report shall include findings in
the following areas:
``(1) The eligibility determination process.
``(2) The provision of cash benefits.
``(3) Quality assurance and protection against waste,
fraud, and abuse.
``(4) Recouping of unpaid and accrued benefits.
``SEC. 3210. TAX TREATMENT OF PROGRAM.
``The CLASS program shall be treated for purposes of the
Internal Revenue Code of 1986 in the same manner as a
qualified long-term care insurance contract for qualified
long-term care services.''.
(2) Conforming amendments to medicaid.--Section 1902(a) of
the Social Security Act (42 U.S.C. 1396a(a)), as amended by
section 6505, is amended by inserting after paragraph (80)
the following:
``(81) provide that the State will comply with such
regulations regarding the application of primary and
secondary payor rules with respect to individuals who are
eligible for medical assistance under this title and are
eligible beneficiaries under the CLASS program established
under title XXXII of the Public Health Service Act as the
Secretary shall establish; and''.
(b) Assurance of Adequate Infrastructure for the Provision
of Personal Care Attendant Workers.--Section 1902(a) of the
Social Security Act (42 U.S.C. 1396a(a)), as amended by
subsection (a)(2), is amended by inserting after paragraph
(81) the following:
``(82) provide that, not later than 2 years after the date
of enactment of the Community Living Assistance Services and
Supports Act, each State shall--
``(A) assess the extent to which entities such as providers
of home care, home health services, home and community
service providers, public
[[Page H2107]]
authorities created to provide personal care services to
individuals eligible for medical assistance under the State
plan, and nonprofit organizations, are serving or have the
capacity to serve as fiscal agents for, employers of, and
providers of employment-related benefits for, personal care
attendant workers who provide personal care services to
individuals receiving benefits under the CLASS program
established under title XXXII of the Public Health Service
Act, including in rural and underserved areas;
``(B) designate or create such entities to serve as fiscal
agents for, employers of, and providers of employment-related
benefits for, such workers to ensure an adequate supply of
the workers for individuals receiving benefits under the
CLASS program, including in rural and underserved areas; and
``(C) ensure that the designation or creation of such
entities will not negatively alter or impede existing
programs, models, methods, or administration of service
delivery that provide for consumer controlled or self-
directed home and community services and further ensure that
such entities will not impede the ability of individuals to
direct and control their home and community services,
including the ability to select, manage, dismiss, co-employ,
or employ such workers or inhibit such individuals from
relying on family members for the provision of personal care
services.''.
(c) Personal Care Attendants Workforce Advisory Panel.--
(1) Establishment.--Not later than 90 days after the date
of enactment of this Act, the Secretary of Health and Human
Services shall establish a Personal Care Attendants Workforce
Advisory Panel for the purpose of examining and advising the
Secretary and Congress on workforce issues related to
personal care attendant workers, including with respect to
the adequacy of the number of such workers, the salaries,
wages, and benefits of such workers, and access to the
services provided by such workers.
(2) Membership.--In appointing members to the Personal Care
Attendants Workforce Advisory Panel, the Secretary shall
ensure that such members include the following:
(A) Individuals with disabilities of all ages.
(B) Senior individuals.
(C) Representatives of individuals with disabilities.
(D) Representatives of senior individuals.
(E) Representatives of workforce and labor organizations.
(F) Representatives of home and community-based service
providers.
(G) Representatives of assisted living providers.
(d) Inclusion of Information on Supplemental Coverage in
the National Clearinghouse for Long-term Care Information;
Extension of Funding.--Section 6021(d) of the Deficit
Reduction Act of 2005 (42 U.S.C. 1396p note) is amended--
(1) in paragraph (2)(A)--
(A) in clause (ii), by striking ``and'' at the end;
(B) in clause (iii), by striking the period at the end and
inserting ``; and''; and
(C) by adding at the end the following:
``(iv) include information regarding the CLASS program
established under title XXXII of the Public Health Service
Act and coverage available for purchase through a Exchange
established under section 1311 of the Patient Protection and
Affordable Care Act that is supplemental coverage to the
benefits provided under a CLASS Independence Benefit Plan
under that program, and information regarding how benefits
provided under a CLASS Independence Benefit Plan differ from
disability insurance benefits.''; and
(2) in paragraph (3), by striking ``2010'' and inserting
``2015''.
(e) Effective Date.--The amendments made by subsections
(a), (b), and (d) take effect on January 1, 2011.
(f) Rule of Construction.--Nothing in this title or the
amendments made by this title are intended to replace or
displace public or private disability insurance benefits,
including such benefits that are for income replacement.
TITLE IX--REVENUE PROVISIONS
Subtitle A--Revenue Offset Provisions
SEC. 9001. EXCISE TAX ON HIGH COST EMPLOYER-SPONSORED HEALTH
COVERAGE.
(a) In General.--Chapter 43 of the Internal Revenue Code of
1986, as amended by section 1513, is amended by adding at the
end the following:
``SEC. 4980I. EXCISE TAX ON HIGH COST EMPLOYER-SPONSORED
HEALTH COVERAGE.
``(a) Imposition of Tax.--If--
``(1) an employee is covered under any applicable employer-
sponsored coverage of an employer at any time during a
taxable period, and
``(2) there is any excess benefit with respect to the
coverage,
there is hereby imposed a tax equal to 40 percent of the
excess benefit.
``(b) Excess Benefit.--For purposes of this section--
``(1) In general.--The term `excess benefit' means, with
respect to any applicable employer-sponsored coverage made
available by an employer to an employee during any taxable
period, the sum of the excess amounts determined under
paragraph (2) for months during the taxable period.
``(2) Monthly excess amount.--The excess amount determined
under this paragraph for any month is the excess (if any)
of--
``(A) the aggregate cost of the applicable employer-
sponsored coverage of the employee for the month, over
``(B) an amount equal to \1/12\ of the annual limitation
under paragraph (3) for the calendar year in which the month
occurs.
``(3) Annual limitation.--For purposes of this subsection--
``(A) In general.--The annual limitation under this
paragraph for any calendar year is the dollar limit
determined under subparagraph (C) for the calendar year.
``(B) Applicable annual limitation.--The annual limitation
which applies for any month shall be determined on the basis
of the type of coverage (as determined under subsection
(f)(1)) provided to the employee by the employer as of the
beginning of the month.
``(C) Applicable dollar limit.--Except as provided in
subparagraph (D)--
``(i) 2013.--In the case of 2013, the dollar limit under
this subparagraph is--
``(I) in the case of an employee with self-only coverage,
$8,500, and
``(II) in the case of an employee with coverage other than
self-only coverage, $23,000.
``(ii) Exception for certain individuals.--In the case of
an individual who is a qualified retiree or who participates
in a plan sponsored by an employer the majority of whose
employees are engaged in a high-risk profession or employed
to repair or install electrical or telecommunications lines--
``(I) the dollar amount in clause (i)(I) (determined after
the application of subparagraph (D)) shall be increased by
$1,350, and
``(II) the dollar amount in clause (i)(II) (determined
after the application of subparagraph (D)) shall be increased
by $3,000.
``(iii) Subsequent years.--In the case of any calendar year
after 2013, each of the dollar amounts under clauses (i) and
(ii) shall be increased to the amount equal to such amount as
in effect for the calendar year preceding such year,
increased by an amount equal to the product of--
``(I) such amount as so in effect, multiplied by
``(II) the cost-of-living adjustment determined under
section 1(f)(3) for such year (determined by substituting the
calendar year that is 2 years before such year for `1992' in
subparagraph (B) thereof), increased by 1 percentage point.
If any amount determined under this clause is not a multiple
of $50, such amount shall be rounded to the nearest multiple
of $50.
``(D) Transition rule for states with highest coverage
costs.--
``(i) In general.--If an employee is a resident of a high
cost State on the first day of any month beginning in 2013,
2014, or 2015, the annual limitation under this paragraph for
such month with respect to such employee shall be an amount
equal to the applicable percentage of the annual limitation
(determined without regard to this subparagraph or
subparagraph (C)(ii)).
``(ii) Applicable percentage.--The applicable percentage is
120 percent for 2013, 110 percent for 2014, and 105 percent
for 2015.
``(iii) High cost state.--The term `high cost State' means
each of the 17 States which the Secretary of Health and Human
Services, in consultation with the Secretary, estimates had
the highest average cost during 2012 for employer-sponsored
coverage under health plans. The Secretary's estimate shall
be made on the basis of aggregate premiums paid in the State
for such health plans, determined using the most recent data
available as of August 31, 2012.
``(c) Liability To Pay Tax.--
``(1) In general.--Each coverage provider shall pay the tax
imposed by subsection (a) on its applicable share of the
excess benefit with respect to an employee for any taxable
period.
``(2) Coverage provider.--For purposes of this subsection,
the term `coverage provider' means each of the following:
``(A) Health insurance coverage.--If the applicable
employer-sponsored coverage consists of coverage under a
group health plan which provides health insurance coverage,
the health insurance issuer.
``(B) HSA and msa contributions.--If the applicable
employer-sponsored coverage consists of coverage under an
arrangement under which the employer makes contributions
described in subsection (b) or (d) of section 106, the
employer.
``(C) Other coverage.--In the case of any other applicable
employer-sponsored coverage, the person that administers the
plan benefits.
``(3) Applicable share.--For purposes of this subsection, a
coverage provider's applicable share of an excess benefit for
any taxable period is the amount which bears the same ratio
to the amount of such excess benefit as--
``(A) the cost of the applicable employer-sponsored
coverage provided by the provider to the employee during such
period, bears to
``(B) the aggregate cost of all applicable employer-
sponsored coverage provided to the employee by all coverage
providers during such period.
``(4) Responsibility to calculate tax and applicable
shares.--
``(A) In general.--Each employer shall--
``(i) calculate for each taxable period the amount of the
excess benefit subject to the tax imposed by subsection (a)
and the applicable share of such excess benefit for each
coverage provider, and
``(ii) notify, at such time and in such manner as the
Secretary may prescribe, the Secretary and each coverage
provider of the amount so determined for the provider.
``(B) Special rule for multiemployer plans.--In the case of
applicable employer-sponsored coverage made available to
employees through a multiemployer plan (as defined in section
414(f)), the plan sponsor shall make the calculations, and
provide the notice, required under subparagraph (A).
``(d) Applicable Employer-Sponsored Coverage; Cost.--For
purposes of this section--
``(1) Applicable employer-sponsored coverage.--
``(A) In general.--The term `applicable employer-sponsored
coverage' means, with respect to any employee, coverage under
any group health plan made available to the employee by an
employer which is excludable from the employee's gross income
under section 106, or
[[Page H2108]]
would be so excludable if it were employer-provided coverage
(within the meaning of such section 106).
``(B) Exceptions.--The term `applicable employer-sponsored
coverage' shall not include--
``(i) any coverage (whether through insurance or otherwise)
described in section 9832(c)(1)(A) or for long-term care, or
``(ii) any coverage described in section 9832(c)(3) the
payment for which is not excludable from gross income and for
which a deduction under section 162(l) is not allowable.
``(C) Coverage includes employee paid portion.--Coverage
shall be treated as applicable employer-sponsored coverage
without regard to whether the employer or employee pays for
the coverage.
``(D) Self-employed individual.--In the case of an
individual who is an employee within the meaning of section
401(c)(1), coverage under any group health plan providing
health insurance coverage shall be treated as applicable
employer-sponsored coverage if a deduction is allowable under
section 162(l) with respect to all or any portion of the cost
of the coverage.
``(E) Governmental plans included.--Applicable employer-
sponsored coverage shall include coverage under any group
health plan established and maintained primarily for its
civilian employees by the Government of the United States, by
the government of any State or political subdivision thereof,
or by any agency or instrumentality of any such government.
``(2) Determination of cost.--
``(A) In general.--The cost of applicable employer-
sponsored coverage shall be determined under rules similar to
the rules of section 4980B(f)(4), except that in determining
such cost, any portion of the cost of such coverage which is
attributable to the tax imposed under this section shall not
be taken into account and the amount of such cost shall be
calculated separately for self-only coverage and other
coverage. In the case of applicable employer-sponsored
coverage which provides coverage to retired employees, the
plan may elect to treat a retired employee who has not
attained the age of 65 and a retired employee who has
attained the age of 65 as similarly situated beneficiaries.
``(B) Health fsas.--In the case of applicable employer-
sponsored coverage consisting of coverage under a flexible
spending arrangement (as defined in section 106(c)(2)), the
cost of the coverage shall be equal to the sum of--
``(i) the amount of employer contributions under any salary
reduction election under the arrangement, plus
``(ii) the amount determined under subparagraph (A) with
respect to any reimbursement under the arrangement in excess
of the contributions described in clause (i).
``(C) Archer msas and hsas.--In the case of applicable
employer-sponsored coverage consisting of coverage under an
arrangement under which the employer makes contributions
described in subsection (b) or (d) of section 106, the cost
of the coverage shall be equal to the amount of employer
contributions under the arrangement.
``(D) Allocation on a monthly basis.--If cost is determined
on other than a monthly basis, the cost shall be allocated to
months in a taxable period on such basis as the Secretary may
prescribe.
``(e) Penalty for Failure To Properly Calculate Excess
Benefit.--
``(1) In general.--If, for any taxable period, the tax
imposed by subsection (a) exceeds the tax determined under
such subsection with respect to the total excess benefit
calculated by the employer or plan sponsor under subsection
(c)(4)--
``(A) each coverage provider shall pay the tax on its
applicable share (determined in the same manner as under
subsection (c)(4)) of the excess, but no penalty shall be
imposed on the provider with respect to such amount, and
``(B) the employer or plan sponsor shall, in addition to
any tax imposed by subsection (a), pay a penalty in an amount
equal to such excess, plus interest at the underpayment rate
determined under section 6621 for the period beginning on the
due date for the payment of tax imposed by subsection (a) to
which the excess relates and ending on the date of payment of
the penalty.
``(2) Limitations on penalty.--
``(A) Penalty not to apply where failure not discovered
exercising reasonable diligence.--No penalty shall be imposed
by paragraph (1)(B) on any failure to properly calculate the
excess benefit during any period for which it is established
to the satisfaction of the Secretary that the employer or
plan sponsor neither knew, nor exercising reasonable
diligence would have known, that such failure existed.
``(B) Penalty not to apply to failures corrected within 30
days.--No penalty shall be imposed by paragraph (1)(B) on any
such failure if--
``(i) such failure was due to reasonable cause and not to
willful neglect, and
``(ii) such failure is corrected during the 30-day period
beginning on the 1st date that the employer knew, or
exercising reasonable diligence would have known, that such
failure existed.
``(C) Waiver by secretary.--In the case of any such failure
which is due to reasonable cause and not to willful neglect,
the Secretary may waive part or all of the penalty imposed by
paragraph (1), to the extent that the payment of such penalty
would be excessive or otherwise inequitable relative to the
failure involved.
``(f) Other Definitions and Special Rules.--For purposes of
this section--
``(1) Coverage determinations.--
``(A) In general.--Except as provided in subparagraph (B),
an employee shall be treated as having self-only coverage
with respect to any applicable employer-sponsored coverage of
an employer.
``(B) Minimum essential coverage.--An employee shall be
treated as having coverage other than self-only coverage only
if the employee is enrolled in coverage other than self-only
coverage in a group health plan which provides minimum
essential coverage (as defined in section 5000A(f)) to the
employee and at least one other beneficiary, and the benefits
provided under such minimum essential coverage do not vary
based on whether any individual covered under such coverage
is the employee or another beneficiary.
``(2) Qualified retiree.--The term `qualified retiree'
means any individual who--
``(A) is receiving coverage by reason of being a retiree,
``(B) has attained age 55, and
``(C) is not entitled to benefits or eligible for
enrollment under the Medicare program under title XVIII of
the Social Security Act.
``(3) Employees engaged in high-risk profession.--The term
`employees engaged in a high-risk profession' means law
enforcement officers (as such term is defined in section 1204
of the Omnibus Crime Control and Safe Streets Act of 1968),
employees in fire protection activities (as such term is
defined in section 3(y) of the Fair Labor Standards Act of
1938), individuals who provide out-of-hospital emergency
medical care (including emergency medical technicians,
paramedics, and first-responders), and individuals engaged in
the construction, mining, agriculture (not including food
processing), forestry, and fishing industries. Such term
includes an employee who is retired from a high-risk
profession described in the preceding sentence, if such
employee satisfied the requirements of such sentence for a
period of not less than 20 years during the employee's
employment.
``(4) Group health plan.--The term `group health plan' has
the meaning given such term by section 5000(b)(1).
``(5) Health insurance coverage; health insurance issuer.--
``(A) Health insurance coverage.--The term `health
insurance coverage' has the meaning given such term by
section 9832(b)(1) (applied without regard to subparagraph
(B) thereof, except as provided by the Secretary in
regulations).
``(B) Health insurance issuer.--The term `health insurance
issuer' has the meaning given such term by section
9832(b)(2).
``(6) Person that administers the plan benefits.--The term
`person that administers the plan benefits' shall include the
plan sponsor if the plan sponsor administers benefits under
the plan.
``(7) Plan sponsor.--The term `plan sponsor' has the
meaning given such term in section 3(16)(B) of the Employee
Retirement Income Security Act of 1974.
``(8) Taxable period.--The term `taxable period' means the
calendar year or such shorter period as the Secretary may
prescribe. The Secretary may have different taxable periods
for employers of varying sizes.
``(9) Aggregation rules.--All employers treated as a single
employer under subsection (b), (c), (m), or (o) of section
414 shall be treated as a single employer.
``(10) Denial of deduction.--For denial of a deduction for
the tax imposed by this section, see section 275(a)(6).
``(g) Regulations.--The Secretary shall prescribe such
regulations as may be necessary to carry out this section.''.
(b) Clerical Amendment.--The table of sections for chapter
43 of such Code, as amended by section 1513, is amended by
adding at the end the following new item:
``Sec. 4980I. Excise tax on high cost employer-sponsored health
coverage.''.
(c) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2012.
SEC. 9002. INCLUSION OF COST OF EMPLOYER-SPONSORED HEALTH
COVERAGE ON W-2.
(a) In General.--Section 6051(a) of the Internal Revenue
Code of 1986 (relating to receipts for employees) is amended
by striking ``and'' at the end of paragraph (12), by striking
the period at the end of paragraph (13) and inserting ``,
and'', and by adding after paragraph (13) the following new
paragraph:
``(14) the aggregate cost (determined under rules similar
to the rules of section 4980B(f)(4)) of applicable employer-
sponsored coverage (as defined in section 4980I(d)(1)),
except that this paragraph shall not apply to--
``(A) coverage to which paragraphs (11) and (12) apply, or
``(B) the amount of any salary reduction contributions to a
flexible spending arrangement (within the meaning of section
125).''.
(b) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2010.
SEC. 9003. DISTRIBUTIONS FOR MEDICINE QUALIFIED ONLY IF FOR
PRESCRIBED DRUG OR INSULIN.
(a) HSAs.--Subparagraph (A) of section 223(d)(2) of the
Internal Revenue Code of 1986 is amended by adding at the end
the following: ``Such term shall include an amount paid for
medicine or a drug only if such medicine or drug is a
prescribed drug (determined without regard to whether such
drug is available without a prescription) or is insulin.''.
(b) Archer MSAs.--Subparagraph (A) of section 220(d)(2) of
the Internal Revenue Code of 1986 is amended by adding at the
end the following: ``Such term shall include an amount paid
for medicine or a drug only if such medicine or drug is a
prescribed drug (determined without regard to whether such
drug is available without a prescription) or is insulin.''.
(c) Health Flexible Spending Arrangements and Health
Reimbursement Arrangements.--Section 106 of the Internal
Revenue Code of 1986 is amended by adding at the end the
following new subsection:
[[Page H2109]]
``(f) Reimbursements for Medicine Restricted to Prescribed
Drugs and Insulin.--For purposes of this section and section
105, reimbursement for expenses incurred for a medicine or a
drug shall be treated as a reimbursement for medical expenses
only if such medicine or drug is a prescribed drug
(determined without regard to whether such drug is available
without a prescription) or is insulin.''.
(d) Effective Dates.--
(1) Distributions from savings accounts.--The amendments
made by subsections (a) and (b) shall apply to amounts paid
with respect to taxable years beginning after December 31,
2010.
(2) Reimbursements.--The amendment made by subsection (c)
shall apply to expenses incurred with respect to taxable
years beginning after December 31, 2010.
SEC. 9004. INCREASE IN ADDITIONAL TAX ON DISTRIBUTIONS FROM
HSAS AND ARCHER MSAS NOT USED FOR QUALIFIED
MEDICAL EXPENSES.
(a) HSAs.--Section 223(f)(4)(A) of the Internal Revenue
Code of 1986 is amended by striking ``10 percent'' and
inserting ``20 percent''.
(b) Archer MSAs.--Section 220(f)(4)(A) of the Internal
Revenue Code of 1986 is amended by striking ``15 percent''
and inserting ``20 percent''.
(c) Effective Date.--The amendments made by this section
shall apply to distributions made after December 31, 2010.
SEC. 9005. LIMITATION ON HEALTH FLEXIBLE SPENDING
ARRANGEMENTS UNDER CAFETERIA PLANS.
(a) In General.--Section 125 of the Internal Revenue Code
of 1986 is amended--
(1) by redesignating subsections (i) and (j) as subsections
(j) and (k), respectively, and
(2) by inserting after subsection (h) the following new
subsection:
``(i) Limitation on Health Flexible Spending
Arrangements.--For purposes of this section, if a benefit is
provided under a cafeteria plan through employer
contributions to a health flexible spending arrangement, such
benefit shall not be treated as a qualified benefit unless
the cafeteria plan provides that an employee may not elect
for any taxable year to have salary reduction contributions
in excess of $2,500 made to such arrangement.''.
(b) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2010.
SEC. 9006. EXPANSION OF INFORMATION REPORTING REQUIREMENTS.
(a) In General.--Section 6041 of the Internal Revenue Code
of 1986 is amended by adding at the end the following new
subsections:
``(h) Application to Corporations.--Notwithstanding any
regulation prescribed by the Secretary before the date of the
enactment of this subsection, for purposes of this section
the term `person' includes any corporation that is not an
organization exempt from tax under section 501(a).
``(i) Regulations.--The Secretary may prescribe such
regulations and other guidance as may be appropriate or
necessary to carry out the purposes of this section,
including rules to prevent duplicative reporting of
transactions.''.
(b) Payments for Property and Other Gross Proceeds.--
Subsection (a) of section 6041 of the Internal Revenue Code
of 1986 is amended--
(1) by inserting ``amounts in consideration for property,''
after ``wages,'',
(2) by inserting ``gross proceeds,'' after ``emoluments, or
other'', and
(3) by inserting ``gross proceeds,'' after ``setting forth
the amount of such''.
(c) Effective Date.--The amendments made by this section
shall apply to payments made after December 31, 2011.
SEC. 9007. ADDITIONAL REQUIREMENTS FOR CHARITABLE HOSPITALS.
(a) Requirements To Qualify as Section 501(c)(3) Charitable
Hospital Organization.--Section 501 of the Internal Revenue
Code of 1986 (relating to exemption from tax on corporations,
certain trusts, etc.) is amended by redesignating subsection
(r) as subsection (s) and by inserting after subsection (q)
the following new subsection:
``(r) Additional Requirements for Certain Hospitals.--
``(1) In general.--A hospital organization to which this
subsection applies shall not be treated as described in
subsection (c)(3) unless the organization--
``(A) meets the community health needs assessment
requirements described in paragraph (3),
``(B) meets the financial assistance policy requirements
described in paragraph (4),
``(C) meets the requirements on charges described in
paragraph (5), and
``(D) meets the billing and collection requirement
described in paragraph (6).
``(2) Hospital organizations to which subsection applies.--
``(A) In general.--This subsection shall apply to--
``(i) an organization which operates a facility which is
required by a State to be licensed, registered, or similarly
recognized as a hospital, and
``(ii) any other organization which the Secretary
determines has the provision of hospital care as its
principal function or purpose constituting the basis for its
exemption under subsection (c)(3) (determined without regard
to this subsection).
``(B) Organizations with more than 1 hospital facility.--If
a hospital organization operates more than 1 hospital
facility--
``(i) the organization shall meet the requirements of this
subsection separately with respect to each such facility, and
``(ii) the organization shall not be treated as described
in subsection (c)(3) with respect to any such facility for
which such requirements are not separately met.
``(3) Community health needs assessments.--
``(A) In general.--An organization meets the requirements
of this paragraph with respect to any taxable year only if
the organization--
``(i) has conducted a community health needs assessment
which meets the requirements of subparagraph (B) in such
taxable year or in either of the 2 taxable years immediately
preceding such taxable year, and
``(ii) has adopted an implementation strategy to meet the
community health needs identified through such assessment.
``(B) Community health needs assessment.--A community
health needs assessment meets the requirements of this
paragraph if such community health needs assessment--
``(i) takes into account input from persons who represent
the broad interests of the community served by the hospital
facility, including those with special knowledge of or
expertise in public health, and
``(ii) is made widely available to the public.
``(4) Financial assistance policy.--An organization meets
the requirements of this paragraph if the organization
establishes the following policies:
``(A) Financial assistance policy.--A written financial
assistance policy which includes--
``(i) eligibility criteria for financial assistance, and
whether such assistance includes free or discounted care,
``(ii) the basis for calculating amounts charged to
patients,
``(iii) the method for applying for financial assistance,
``(iv) in the case of an organization which does not have a
separate billing and collections policy, the actions the
organization may take in the event of non-payment, including
collections action and reporting to credit agencies, and
``(v) measures to widely publicize the policy within the
community to be served by the organization.
``(B) Policy relating to emergency medical care.--A written
policy requiring the organization to provide, without
discrimination, care for emergency medical conditions (within
the meaning of section 1867 of the Social Security Act (42
U.S.C. 1395dd)) to individuals regardless of their
eligibility under the financial assistance policy described
in subparagraph (A).
``(5) Limitation on charges.--An organization meets the
requirements of this paragraph if the organization--
``(A) limits amounts charged for emergency or other
medically necessary care provided to individuals eligible for
assistance under the financial assistance policy described in
paragraph (4)(A) to not more than the lowest amounts charged
to individuals who have insurance covering such care, and
``(B) prohibits the use of gross charges.
``(6) Billing and collection requirements.--An organization
meets the requirement of this paragraph only if the
organization does not engage in extraordinary collection
actions before the organization has made reasonable efforts
to determine whether the individual is eligible for
assistance under the financial assistance policy described in
paragraph (4)(A).
``(7) Regulatory authority.--The Secretary shall issue such
regulations and guidance as may be necessary to carry out the
provisions of this subsection, including guidance relating to
what constitutes reasonable efforts to determine the
eligibility of a patient under a financial assistance policy
for purposes of paragraph (6).''.
(b) Excise Tax for Failures To Meet Hospital Exemption
Requirements.--
(1) In general.--Subchapter D of chapter 42 of the Internal
Revenue Code of 1986 (relating to failure by certain
charitable organizations to meet certain qualification
requirements) is amended by adding at the end the following
new section:
``SEC. 4959. TAXES ON FAILURES BY HOSPITAL ORGANIZATIONS.
``If a hospital organization to which section 501(r)
applies fails to meet the requirement of section 501(r)(3)
for any taxable year, there is imposed on the organization a
tax equal to $50,000.''.
(2) Conforming amendment.--The table of sections for
subchapter D of chapter 42 of such Code is amended by adding
at the end the following new item:
``Sec. 4959. Taxes on failures by hospital organizations.''.
(c) Mandatory Review of Tax Exemption for Hospitals.--The
Secretary of the Treasury or the Secretary's delegate shall
review at least once every 3 years the community benefit
activities of each hospital organization to which section
501(r) of the Internal Revenue Code of 1986 (as added by this
section) applies.
(d) Additional Reporting Requirements.--
(1) Community health needs assessments and audited
financial statements.--Section 6033(b) of the Internal
Revenue Code of 1986 (relating to certain organizations
described in section 501(c)(3)) is amended by striking
``and'' at the end of paragraph (14), by redesignating
paragraph (15) as paragraph (16), and by inserting after
paragraph (14) the following new paragraph:
``(15) in the case of an organization to which the
requirements of section 501(r) apply for the taxable year--
``(A) a description of how the organization is addressing
the needs identified in each community health needs
assessment conducted under section 501(r)(3) and a
description of any such needs that are not being addressed
together with the reasons why such needs are not being
addressed, and
``(B) the audited financial statements of such organization
(or, in the case of an organization the financial statements
of which are included in a consolidated financial statement
with other organizations, such consolidated financial
statement).''.
[[Page H2110]]
(2) Taxes.--Section 6033(b)(10) of such Code is amended by
striking ``and'' at the end of subparagraph (B), by inserting
``and'' at the end of subparagraph (C), and by adding at the
end the following new subparagraph:
``(D) section 4959 (relating to taxes on failures by
hospital organizations),''.
(e) Reports.--
(1) Report on levels of charity care.--The Secretary of the
Treasury, in consultation with the Secretary of Health and
Human Services, shall submit to the Committees on Ways and
Means, Education and Labor, and Energy and Commerce of the
House of Representatives and to the Committees on Finance and
Health, Education, Labor, and Pensions of the Senate an
annual report on the following:
(A) Information with respect to private tax-exempt,
taxable, and government-owned hospitals regarding--
(i) levels of charity care provided,
(ii) bad debt expenses,
(iii) unreimbursed costs for services provided with respect
to means-tested government programs, and
(iv) unreimbursed costs for services provided with respect
to non-means tested government programs.
(B) Information with respect to private tax-exempt
hospitals regarding costs incurred for community benefit
activities.
(2) Report on trends.--
(A) Study.--The Secretary of the Treasury, in consultation
with the Secretary of Health and Human Services, shall
conduct a study on trends in the information required to be
reported under paragraph (1).
(B) Report.--Not later than 5 years after the date of the
enactment of this Act, the Secretary of the Treasury, in
consultation with the Secretary of Health and Human Services,
shall submit a report on the study conducted under
subparagraph (A) to the Committees on Ways and Means,
Education and Labor, and Energy and Commerce of the House of
Representatives and to the Committees on Finance and Health,
Education, Labor, and Pensions of the Senate.
(f) Effective Dates.--
(1) In general.--Except as provided in paragraphs (2) and
(3), the amendments made by this section shall apply to
taxable years beginning after the date of the enactment of
this Act.
(2) Community health needs assessment.--The requirements of
section 501(r)(3) of the Internal Revenue Code of 1986, as
added by subsection (a), shall apply to taxable years
beginning after the date which is 2 years after the date of
the enactment of this Act.
(3) Excise tax.--The amendments made by subsection (b)
shall apply to failures occurring after the date of the
enactment of this Act.
SEC. 9008. IMPOSITION OF ANNUAL FEE ON BRANDED PRESCRIPTION
PHARMACEUTICAL MANUFACTURERS AND IMPORTERS.
(a) Imposition of Fee.--
(1) In general.--Each covered entity engaged in the
business of manufacturing or importing branded prescription
drugs shall pay to the Secretary of the Treasury not later
than the annual payment date of each calendar year beginning
after 2009 a fee in an amount determined under subsection
(b).
(2) Annual payment date.--For purposes of this section, the
term ``annual payment date'' means with respect to any
calendar year the date determined by the Secretary, but in no
event later than September 30 of such calendar year.
(b) Determination of Fee Amount.--
(1) In general.--With respect to each covered entity, the
fee under this section for any calendar year shall be equal
to an amount that bears the same ratio to $2,300,000,000 as--
(A) the covered entity's branded prescription drug sales
taken into account during the preceding calendar year, bear
to
(B) the aggregate branded prescription drug sales of all
covered entities taken into account during such preceding
calendar year.
(2) Sales taken into account.--For purposes of paragraph
(1), the branded prescription drug sales taken into account
during any calendar year with respect to any covered entity
shall be determined in accordance with the following table:
With respect to a covered entity's
aggregate branded prescription drug The percentage of such sales
sales during the calendar year that taken into account is:
are:
Not more than $5,000,000............. 0 percent
More than $5,000,000 but not more 10 percent
than $125,000,000.
More than $125,000,000 but not more 40 percent
than $225,000,000.
More than $225,000,000 but not more 75 percent
than $400,000,000.
More than $400,000,000............... 100 percent.
(3) Secretarial determination.--The Secretary of the
Treasury shall calculate the amount of each covered entity's
fee for any calendar year under paragraph (1). In calculating
such amount, the Secretary of the Treasury shall determine
such covered entity's branded prescription drug sales on the
basis of reports submitted under subsection (g) and through
the use of any other source of information available to the
Secretary of the Treasury.
(c) Transfer of Fees to Medicare Part B Trust Fund.--There
is hereby appropriated to the Federal Supplementary Medical
Insurance Trust Fund established under section 1841 of the
Social Security Act an amount equal to the fees received by
the Secretary of the Treasury under subsection (a).
(d) Covered Entity.--
(1) In general.--For purposes of this section, the term
``covered entity'' means any manufacturer or importer with
gross receipts from branded prescription drug sales.
(2) Controlled groups.--
(A) In general.--For purposes of this subsection, all
persons treated as a single employer under subsection (a) or
(b) of section 52 of the Internal Revenue Code of 1986 or
subsection (m) or (o) of section 414 of such Code shall be
treated as a single covered entity.
(B) Inclusion of foreign corporations.--For purposes of
subparagraph (A), in applying subsections (a) and (b) of
section 52 of such Code to this section, section 1563 of such
Code shall be applied without regard to subsection (b)(2)(C)
thereof.
(e) Branded Prescription Drug Sales.--For purposes of this
section--
(1) In general.--The term ``branded prescription drug
sales'' means sales of branded prescription drugs to any
specified government program or pursuant to coverage under
any such program.
(2) Branded prescription drugs.--
(A) In general.--The term ``branded prescription drug''
means--
(i) any prescription drug the application for which was
submitted under section 505(b) of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 355(b)), or
(ii) any biological product the license for which was
submitted under section 351(a) of the Public Health Service
Act (42 U.S.C. 262(a)).
(B) Prescription drug.--For purposes of subparagraph
(A)(i), the term ``prescription drug'' means any drug which
is subject to section 503(b) of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 353(b)).
(3) Exclusion of orphan drug sales.--The term ``branded
prescription drug sales'' shall not include sales of any drug
or biological product with respect to which a credit was
allowed for any taxable year under section 45C of the
Internal Revenue Code of 1986. The preceding sentence shall
not apply with respect to any such drug or biological product
after the date on which such drug or biological product is
approved by the Food and Drug Administration for marketing
for any indication other than the treatment of the rare
disease or condition with respect to which such credit was
allowed.
(4) Specified government program.--The term ``specified
government program'' means--
(A) the Medicare Part D program under part D of title XVIII
of the Social Security Act,
(B) the Medicare Part B program under part B of title XVIII
of the Social Security Act,
(C) the Medicaid program under title XIX of the Social
Security Act,
(D) any program under which branded prescription drugs are
procured by the Department of Veterans Affairs,
(E) any program under which branded prescription drugs are
procured by the Department of Defense, or
(F) the TRICARE retail pharmacy program under section 1074g
of title 10, United States Code.
(f) Tax Treatment of Fees.--The fees imposed by this
section--
(1) for purposes of subtitle F of the Internal Revenue Code
of 1986, shall be treated as excise taxes with respect to
which only civil actions for refund under procedures of such
subtitle shall apply, and
(2) for purposes of section 275 of such Code, shall be
considered to be a tax described in section 275(a)(6).
(g) Reporting Requirement.--Not later than the date
determined by the Secretary of the Treasury following the end
of any calendar year, the Secretary of Health and Human
Services, the Secretary of Veterans Affairs, and the
Secretary of Defense shall report to the Secretary of the
Treasury, in such manner as the Secretary of the Treasury
prescribes, the total branded prescription drug sales for
each covered entity with respect to each specified government
program under such Secretary's jurisdiction using the
following methodology:
(1) Medicare part d program.--The Secretary of Health and
Human Services shall report, for each covered entity and for
each branded prescription drug of the covered entity covered
by the Medicare Part D program, the product of--
(A) the per-unit ingredient cost, as reported to the
Secretary of Health and Human Services by prescription drug
plans and Medicare Advantage prescription drug plans, minus
any per-unit rebate, discount, or other price concession
provided by the covered entity, as reported to the Secretary
of Health and Human Services by the prescription drug plans
and Medicare Advantage prescription drug plans, and
(B) the number of units of the branded prescription drug
paid for under the Medicare Part D program.
(2) Medicare part b program.--The Secretary of Health and
Human Services shall report, for each covered entity and for
each branded prescription drug of the covered entity covered
by the Medicare Part B program under section 1862(a) of the
Social Security Act, the product of--
(A) the per-unit average sales price (as defined in section
1847A(c) of the Social Security
[[Page H2111]]
Act) or the per-unit Part B payment rate for a separately
paid branded prescription drug without a reported average
sales price, and
(B) the number of units of the branded prescription drug
paid for under the Medicare Part B program.
The Centers for Medicare and Medicaid Services shall
establish a process for determining the units and the
allocated price for purposes of this section for those
branded prescription drugs that are not separately payable or
for which National Drug Codes are not reported.
(3) Medicaid program.--The Secretary of Health and Human
Services shall report, for each covered entity and for each
branded prescription drug of the covered entity covered under
the Medicaid program, the product of--
(A) the per-unit ingredient cost paid to pharmacies by
States for the branded prescription drug dispensed to
Medicaid beneficiaries, minus any per-unit rebate paid by the
covered entity under section 1927 of the Social Security Act
and any State supplemental rebate, and
(B) the number of units of the branded prescription drug
paid for under the Medicaid program.
(4) Department of veterans affairs programs.--The Secretary
of Veterans Affairs shall report, for each covered entity and
for each branded prescription drug of the covered entity the
total amount paid for each such branded prescription drug
procured by the Department of Veterans Affairs for its
beneficiaries.
(5) Department of defense programs and tricare.--The
Secretary of Defense shall report, for each covered entity
and for each branded prescription drug of the covered entity,
the sum of--
(A) the total amount paid for each such branded
prescription drug procured by the Department of Defense for
its beneficiaries, and
(B) for each such branded prescription drug dispensed under
the TRICARE retail pharmacy program, the product of--
(i) the per-unit ingredient cost, minus any per-unit rebate
paid by the covered entity, and
(ii) the number of units of the branded prescription drug
dispensed under such program.
(h) Secretary.--For purposes of this section, the term
``Secretary'' includes the Secretary's delegate.
(i) Guidance.--The Secretary of the Treasury shall publish
guidance necessary to carry out the purposes of this section.
(j) Application of Section.--This section shall apply to
any branded prescription drug sales after December 31, 2008.
(k) Conforming Amendment.--Section 1841(a) of the Social
Security Act is amended by inserting ``or section 9008(c) of
the Patient Protection and Affordable Care Act of 2009''
after ``this part''.
SEC. 9009. IMPOSITION OF ANNUAL FEE ON MEDICAL DEVICE
MANUFACTURERS AND IMPORTERS.
(a) Imposition of Fee.--
(1) In general.--Each covered entity engaged in the
business of manufacturing or importing medical devices shall
pay to the Secretary not later than the annual payment date
of each calendar year beginning after 2009 a fee in an amount
determined under subsection (b).
(2) Annual payment date.--For purposes of this section, the
term ``annual payment date'' means with respect to any
calendar year the date determined by the Secretary, but in no
event later than September 30 of such calendar year.
(b) Determination of Fee Amount.--
(1) In general.--With respect to each covered entity, the
fee under this section for any calendar year shall be equal
to an amount that bears the same ratio to $2,000,000,000 as--
(A) the covered entity's gross receipts from medical device
sales taken into account during the preceding calendar year,
bear to
(B) the aggregate gross receipts of all covered entities
from medical device sales taken into account during such
preceding calendar year.
(2) Gross receipts from sales taken into account.--For
purposes of paragraph (1), the gross receipts from medical
device sales taken into account during any calendar year with
respect to any covered entity shall be determined in
accordance with the following table:
With respect to a covered entity's
aggregate gross receipts from medical The percentage of gross
device sales during the calendar year receipts taken into account is:
that are:
Not more than $5,000,000............. 0 percent
More than $5,000,000 but not more 50 percent
than $25,000,000.
More than $25,000,000................ 100 percent.
(3) Secretarial determination.--The Secretary shall
calculate the amount of each covered entity's fee for any
calendar year under paragraph (1). In calculating such
amount, the Secretary shall determine such covered entity's
gross receipts from medical device sales on the basis of
reports submitted by the covered entity under subsection (f)
and through the use of any other source of information
available to the Secretary.
(c) Covered Entity.--
(1) In general.--For purposes of this section, the term
``covered entity'' means any manufacturer or importer with
gross receipts from medical device sales.
(2) Controlled groups.--
(A) In general.--For purposes of this subsection, all
persons treated as a single employer under subsection (a) or
(b) of section 52 of the Internal Revenue Code of 1986 or
subsection (m) or (o) of section 414 of such Code shall be
treated as a single covered entity.
(B) Inclusion of foreign corporations.--For purposes of
subparagraph (A), in applying subsections (a) and (b) of
section 52 of such Code to this section, section 1563 of such
Code shall be applied without regard to subsection (b)(2)(C)
thereof.
(d) Medical Device Sales.--For purposes of this section--
(1) In general.--The term ``medical device sales'' means
sales for use in the United States of any medical device,
other than the sales of a medical device that--
(A) has been classified in class II under section 513 of
the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360c) and
is primarily sold to consumers at retail for not more than
$100 per unit, or
(B) has been classified in class I under such section.
(2) United states.--For purposes of paragraph (1), the term
``United States'' means the several States, the District of
Columbia, the Commonwealth of Puerto Rico, and the
possessions of the United States.
(3) Medical device.--For purposes of paragraph (1), the
term ``medical device'' means any device (as defined in
section 201(h) of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. 321(h))) intended for humans.
(e) Tax Treatment of Fees.--The fees imposed by this
section--
(1) for purposes of subtitle F of the Internal Revenue Code
of 1986, shall be treated as excise taxes with respect to
which only civil actions for refund under procedures of such
subtitle shall apply, and
(2) for purposes of section 275 of such Code, shall be
considered to be a tax described in section 275(a)(6).
(f) Reporting Requirement.--
(1) In general.--Not later than the date determined by the
Secretary following the end of any calendar year, each
covered entity shall report to the Secretary, in such manner
as the Secretary prescribes, the gross receipts from medical
device sales of such covered entity during such calendar
year.
(2) Penalty for failure to report.--
(A) In general.--In the case of any failure to make a
report containing the information required by paragraph (1)
on the date prescribed therefor (determined with regard to
any extension of time for filing), unless it is shown that
such failure is due to reasonable cause, there shall be paid
by the covered entity failing to file such report, an amount
equal to--
(i) $10,000, plus
(ii) the lesser of--
(I) an amount equal to $1,000, multiplied by the number of
days during which such failure continues, or
(II) the amount of the fee imposed by this section for
which such report was required.
(B) Treatment of penalty.--The penalty imposed under
subparagraph (A)--
(i) shall be treated as a penalty for purposes of subtitle
F of the Internal Revenue Code of 1986,
(ii) shall be paid on notice and demand by the Secretary
and in the same manner as tax under such Code, and
(iii) with respect to which only civil actions for refund
under procedures of such subtitle F shall apply.
(g) Secretary.--For purposes of this section, the term
``Secretary'' means the Secretary of the Treasury or the
Secretary's delegate.
(h) Guidance.--The Secretary shall publish guidance
necessary to carry out the purposes of this section,
including identification of medical devices described in
subsection (d)(1)(A) and with respect to the treatment of
gross receipts from sales of medical devices to another
covered entity or to another entity by reason of the
application of subsection (c)(2).
(i) Application of Section.--This section shall apply to
any medical device sales after December 31, 2008.
SEC. 9010. IMPOSITION OF ANNUAL FEE ON HEALTH INSURANCE
PROVIDERS.
(a) Imposition of Fee.--
(1) In general.--Each covered entity engaged in the
business of providing health insurance shall pay to the
Secretary not later than the annual payment date of each
calendar year beginning after 2009 a fee in an amount
determined under subsection (b).
(2) Annual payment date.--For purposes of this section, the
term ``annual payment date'' means with respect to any
calendar year the date determined by the Secretary, but in no
event later than September 30 of such calendar year.
(b) Determination of Fee Amount.--
(1) In general.--With respect to each covered entity, the
fee under this section for any calendar year shall be equal
to an amount that bears the same ratio to $6,700,000,000 as--
(A) the sum of--
(i) the covered entity's net premiums written with respect
to health insurance for any United States health risk that
are taken into account during the preceding calendar year,
plus
(ii) 200 percent of the covered entity's third party
administration agreement fees that are taken into account
during the preceding calendar year, bears to
(B) the sum of--
[[Page H2112]]
(i) the aggregate net premiums written with respect to such
health insurance of all covered entities that are taken into
account during such preceding calendar year, plus
(ii) 200 percent of the aggregate third party
administration agreement fees of all covered entities that
are taken into account during such preceding calendar year.
(2) Amounts taken into account.--For purposes of paragraph
(1)--
(A) Net premiums written.--The net premiums written with
respect to health insurance for any United States health risk
that are taken into account during any calendar year with
respect to any covered entity shall be determined in
accordance with the following table:
With respect to a covered entity's net The percentage of net premiums
premiums written during the calendar written that are taken into
year that are: account is:
Not more than $25,000,000............ 0 percent
More than $25,000,000 but not more 50 percent
than $50,000,000.
More than $50,000,000................ 100 percent.
(B) Third party administration agreement fees.--The third
party administration agreement fees that are taken into
account during any calendar year with respect to any covered
entity shall be determined in accordance with the following
table:
With respect to a covered entity's The percentage of third party
third party administration agreement administration agreement fees
fees during the calendar year that are: that are taken into account is:
Not more than $5,000,000............. 0 percent
More than $5,000,000 but not more 50 percent
than $10,000,000.
More than $10,000,000................ 100 percent.
(3) Secretarial determination.--The Secretary shall
calculate the amount of each covered entity's fee for any
calendar year under paragraph (1). In calculating such
amount, the Secretary shall determine such covered entity's
net premiums written with respect to any United States health
risk and third party administration agreement fees on the
basis of reports submitted by the covered entity under
subsection (g) and through the use of any other source of
information available to the Secretary.
(c) Covered Entity.--
(1) In general.--For purposes of this section, the term
``covered entity'' means any entity which provides health
insurance for any United States health risk.
(2) Exclusion.--Such term does not include--
(A) any employer to the extent that such employer self-
insures its employees' health risks, or
(B) any governmental entity (except to the extent such an
entity provides health insurance coverage through the
community health insurance option under section 1323).
(3) Controlled groups.--
(A) In general.--For purposes of this subsection, all
persons treated as a single employer under subsection (a) or
(b) of section 52 of the Internal Revenue Code of 1986 or
subsection (m) or (o) of section 414 of such Code shall be
treated as a single covered entity (or employer for purposes
of paragraph (2)).
(B) Inclusion of foreign corporations.--For purposes of
subparagraph (A), in applying subsections (a) and (b) of
section 52 of such Code to this section, section 1563 of such
Code shall be applied without regard to subsection (b)(2)(C)
thereof.
(d) United States Health Risk.--For purposes of this
section, the term ``United States health risk'' means the
health risk of any individual who is--
(1) a United States citizen,
(2) a resident of the United States (within the meaning of
section 7701(b)(1)(A) of the Internal Revenue Code of 1986),
or
(3) located in the United States, with respect to the
period such individual is so located.
(e) Third Party Administration Agreement Fees.--For
purposes of this section, the term ``third party
administration agreement fees'' means, with respect to any
covered entity, amounts received from an employer which are
in excess of payments made by such covered entity for health
benefits under an arrangement under which such employer self-
insures the United States health risk of its employees.
(f) Tax Treatment of Fees.--The fees imposed by this
section--
(1) for purposes of subtitle F of the Internal Revenue Code
of 1986, shall be treated as excise taxes with respect to
which only civil actions for refund under procedures of such
subtitle shall apply, and
(2) for purposes of section 275 of such Code shall be
considered to be a tax described in section 275(a)(6).
(g) Reporting Requirement.--
(1) In general.--Not later than the date determined by the
Secretary following the end of any calendar year, each
covered entity shall report to the Secretary, in such manner
as the Secretary prescribes, the covered entity's net
premiums written with respect to health insurance for any
United States health risk and third party administration
agreement fees for such calendar year.
(2) Penalty for failure to report.--
(A) In general.--In the case of any failure to make a
report containing the information required by paragraph (1)
on the date prescribed therefor (determined with regard to
any extension of time for filing), unless it is shown that
such failure is due to reasonable cause, there shall be paid
by the covered entity failing to file such report, an amount
equal to--
(i) $10,000, plus
(ii) the lesser of--
(I) an amount equal to $1,000, multiplied by the number of
days during which such failure continues, or
(II) the amount of the fee imposed by this section for
which such report was required.
(B) Treatment of penalty.--The penalty imposed under
subparagraph (A)--
(i) shall be treated as a penalty for purposes of subtitle
F of the Internal Revenue Code of 1986,
(ii) shall be paid on notice and demand by the Secretary
and in the same manner as tax under such Code, and
(iii) with respect to which only civil actions for refund
under procedures of such subtitle F shall apply.
(h) Additional Definitions.--For purposes of this section--
(1) Secretary.--The term ``Secretary'' means the Secretary
of the Treasury or the Secretary's delegate.
(2) United states.--The term ``United States'' means the
several States, the District of Columbia, the Commonwealth of
Puerto Rico, and the possessions of the United States.
(3) Health insurance.--The term ``health insurance'' shall
not include insurance for long-term care or disability.
(i) Guidance.--The Secretary shall publish guidance
necessary to carry out the purposes of this section.
(j) Application of Section.--This section shall apply to
any net premiums written after December 31, 2008, with
respect to health insurance for any United States health
risk, and any third party administration agreement fees
received after such date.
SEC. 9011. STUDY AND REPORT OF EFFECT ON VETERANS HEALTH
CARE.
(a) In General.--The Secretary of Veterans Affairs shall
conduct a study on the effect (if any) of the provisions of
sections 9008, 9009, and 9010 on--
(1) the cost of medical care provided to veterans, and
(2) veterans' access to medical devices and branded
prescription drugs.
(b) Report.--The Secretary of Veterans Affairs shall report
the results of the study under subsection (a) to the
Committee on Ways and Means of the House of Representatives
and to the Committee on Finance of the Senate not later than
December 31, 2012.
SEC. 9012. ELIMINATION OF DEDUCTION FOR EXPENSES ALLOCABLE TO
MEDICARE PART D SUBSIDY.
(a) In General.--Section 139A of the Internal Revenue Code
of 1986 is amended by striking the second sentence.
(b) Effective Date.--The amendment made by this section
shall apply to taxable years beginning after December 31,
2010.
SEC. 9013. MODIFICATION OF ITEMIZED DEDUCTION FOR MEDICAL
EXPENSES.
(a) In General.--Subsection (a) of section 213 of the
Internal Revenue Code of 1986 is amended by striking ``7.5
percent'' and inserting ``10 percent''.
(b) Temporary Waiver of Increase for Certain Seniors.--
Section 213 of the Internal Revenue Code of 1986 is amended
by adding at the end the following new subsection:
``(f) Special Rule for 2013, 2014, 2015, and 2016.--In the
case of any taxable year beginning after December 31, 2012,
and ending before January 1, 2017, subsection (a) shall be
applied with respect to a taxpayer by substituting `7.5
percent' for `10 percent' if such taxpayer or such taxpayer's
spouse has attained age 65 before the close of such taxable
year.''.
(c) Conforming Amendment.--Section 56(b)(1)(B) of the
Internal Revenue Code of 1986 is amended by striking ``by
substituting `10 percent' for `7.5 percent' '' and inserting
``without regard to subsection (f) of such section''.
(d) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2012.
SEC. 9014. LIMITATION ON EXCESSIVE REMUNERATION PAID BY
CERTAIN HEALTH INSURANCE PROVIDERS.
(a) In General.--Section 162(m) of the Internal Revenue
Code of 1986 is amended by adding at the end the following
new subparagraph:
``(6) Special rule for application to certain health
insurance providers.--
[[Page H2113]]
``(A) In general.--No deduction shall be allowed under this
chapter--
``(i) in the case of applicable individual remuneration
which is for any disqualified taxable year beginning after
December 31, 2012, and which is attributable to services
performed by an applicable individual during such taxable
year, to the extent that the amount of such remuneration
exceeds $500,000, or
``(ii) in the case of deferred deduction remuneration for
any taxable year beginning after December 31, 2012, which is
attributable to services performed by an applicable
individual during any disqualified taxable year beginning
after December 31, 2009, to the extent that the amount of
such remuneration exceeds $500,000 reduced (but not below
zero) by the sum of--
``(I) the applicable individual remuneration for such
disqualified taxable year, plus
``(II) the portion of the deferred deduction remuneration
for such services which was taken into account under this
clause in a preceding taxable year (or which would have been
taken into account under this clause in a preceding taxable
year if this clause were applied by substituting `December
31, 2009' for `December 31, 2012' in the matter preceding
subclause (I)).
``(B) Disqualified taxable year.--For purposes of this
paragraph, the term `disqualified taxable year' means, with
respect to any employer, any taxable year for which such
employer is a covered health insurance provider.
``(C) Covered health insurance provider.--For purposes of
this paragraph--
``(i) In general.--The term `covered health insurance
provider' means--
``(I) with respect to taxable years beginning after
December 31, 2009, and before January 1, 2013, any employer
which is a health insurance issuer (as defined in section
9832(b)(2)) and which receives premiums from providing health
insurance coverage (as defined in section 9832(b)(1)), and
``(II) with respect to taxable years beginning after
December 31, 2012, any employer which is a health insurance
issuer (as defined in section 9832(b)(2)) and with respect to
which not less than 25 percent of the gross premiums received
from providing health insurance coverage (as defined in
section 9832(b)(1)) is from minimum essential coverage (as
defined in section 5000A(f)).
``(ii) Aggregation rules.--Two or more persons who are
treated as a single employer under subsection (b), (c), (m),
or (o) of section 414 shall be treated as a single employer,
except that in applying section 1563(a) for purposes of any
such subsection, paragraphs (2) and (3) thereof shall be
disregarded.
``(D) Applicable individual remuneration.--For purposes of
this paragraph, the term `applicable individual remuneration'
means, with respect to any applicable individual for any
disqualified taxable year, the aggregate amount allowable as
a deduction under this chapter for such taxable year
(determined without regard to this subsection) for
remuneration (as defined in paragraph (4) without regard to
subparagraphs (B), (C), and (D) thereof) for services
performed by such individual (whether or not during the
taxable year). Such term shall not include any deferred
deduction remuneration with respect to services performed
during the disqualified taxable year.
``(E) Deferred deduction remuneration.--For purposes of
this paragraph, the term `deferred deduction remuneration'
means remuneration which would be applicable individual
remuneration for services performed in a disqualified taxable
year but for the fact that the deduction under this chapter
(determined without regard to this paragraph) for such
remuneration is allowable in a subsequent taxable year.
``(F) Applicable individual.--For purposes of this
paragraph, the term `applicable individual' means, with
respect to any covered health insurance provider for any
disqualified taxable year, any individual--
``(i) who is an officer, director, or employee in such
taxable year, or
``(ii) who provides services for or on behalf of such
covered health insurance provider during such taxable year.
``(G) Coordination.--Rules similar to the rules of
subparagraphs (F) and (G) of paragraph (4) shall apply for
purposes of this paragraph.
``(H) Regulatory authority.--The Secretary may prescribe
such guidance, rules, or regulations as are necessary to
carry out the purposes of this paragraph.''.
(b) Effective Date.--The amendment made by this section
shall apply to taxable years beginning after December 31,
2009, with respect to services performed after such date.
SEC. 9015. ADDITIONAL HOSPITAL INSURANCE TAX ON HIGH-INCOME
TAXPAYERS.
(a) FICA.--
(1) In general.--Section 3101(b) of the Internal Revenue
Code of 1986 is amended--
(A) by striking ``In addition'' and inserting the
following:
``(1) In general.--In addition'',
(B) by striking ``the following percentages of the'' and
inserting ``1.45 percent of the'',
(C) by striking ``(as defined in section 3121(b))--'' and
all that follows and inserting ``(as defined in section
3121(b)).'', and
(D) by adding at the end the following new paragraph:
``(2) Additional tax.--In addition to the tax imposed by
paragraph (1) and the preceding subsection, there is hereby
imposed on every taxpayer (other than a corporation, estate,
or trust) a tax equal to 0.5 percent of wages which are
received with respect to employment (as defined in section
3121(b)) during any taxable year beginning after December 31,
2012, and which are in excess of--
``(A) in the case of a joint return, $250,000, and
``(B) in any other case, $200,000.''.
(2) Collection of tax.--Section 3102 of the Internal
Revenue Code of 1986 is amended by adding at the end the
following new subsection:
``(f) Special Rules for Additional Tax.--
``(1) In general.--In the case of any tax imposed by
section 3101(b)(2), subsection (a) shall only apply to the
extent to which the taxpayer receives wages from the employer
in excess of $200,000, and the employer may disregard the
amount of wages received by such taxpayer's spouse.
``(2) Collection of amounts not withheld.--To the extent
that the amount of any tax imposed by section 3101(b)(2) is
not collected by the employer, such tax shall be paid by the
employee.
``(3) Tax paid by recipient.--If an employer, in violation
of this chapter, fails to deduct and withhold the tax imposed
by section 3101(b)(2) and thereafter the tax is paid by the
employee, the tax so required to be deducted and withheld
shall not be collected from the employer, but this paragraph
shall in no case relieve the employer from liability for any
penalties or additions to tax otherwise applicable in respect
of such failure to deduct and withhold.''.
(b) SECA.--
(1) In general.--Section 1401(b) of the Internal Revenue
Code of 1986 is amended--
(A) by striking ``In addition'' and inserting the
following:
``(1) In general.--In addition'', and
(B) by adding at the end the following new paragraph:
``(2) Additional tax.--
``(A) In general.--In addition to the tax imposed by
paragraph (1) and the preceding subsection, there is hereby
imposed on every taxpayer (other than a corporation, estate,
or trust) for each taxable year beginning after December 31,
2012, a tax equal to 0.5 percent of the self-employment
income for such taxable year which is in excess of--
``(i) in the case of a joint return, $250,000, and
``(ii) in any other case, $200,000.
``(B) Coordination with fica.--The amounts under clauses
(i) and (ii) of subparagraph (A) shall be reduced (but not
below zero) by the amount of wages taken into account in
determining the tax imposed under section 3121(b)(2) with
respect to the taxpayer.''.
(2) No deduction for additional tax.--
(A) In general.--Section 164(f) of such Code is amended by
inserting ``(other than the taxes imposed by section
1401(b)(2))'' after ``section 1401)''.
(B) Deduction for net earnings from self-employment.--
Subparagraph (B) of section 1402(a)(12) is amended by
inserting ``(determined without regard to the rate imposed
under paragraph (2) of section 1401(b))'' after ``for such
year''.
(c) Effective Date.--The amendments made by this section
shall apply with respect to remuneration received, and
taxable years beginning, after December 31, 2012.
SEC. 9016. MODIFICATION OF SECTION 833 TREATMENT OF CERTAIN
HEALTH ORGANIZATIONS.
(a) In General.--Subsection (c) of section 833 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new paragraph:
``(5) Nonapplication of section in case of low medical loss
ratio.--Notwithstanding the preceding paragraphs, this
section shall not apply to any organization unless such
organization's percentage of total premium revenue expended
on reimbursement for clinical services provided to enrollees
under its policies during such taxable year (as reported
under section 2718 of the Public Health Service Act) is not
less than 85 percent.''.
(b) Effective Date.--The amendment made by this section
shall apply to taxable years beginning after December 31,
2009.
SEC. 9017. EXCISE TAX ON ELECTIVE COSMETIC MEDICAL
PROCEDURES.
(a) In General.--Subtitle D of the Internal Revenue Code of
1986, as amended by this Act, is amended by adding at the end
the following new chapter:
``CHAPTER 49--ELECTIVE COSMETIC MEDICAL PROCEDURES
``Sec. 5000B. Imposition of tax on elective cosmetic medical
procedures.
``SEC. 5000B. IMPOSITION OF TAX ON ELECTIVE COSMETIC MEDICAL
PROCEDURES.
``(a) In General.--There is hereby imposed on any cosmetic
surgery and medical procedure a tax equal to 5 percent of the
amount paid for such procedure (determined without regard to
this section), whether paid by insurance or otherwise.
``(b) Cosmetic Surgery and Medical Procedure.--For purposes
of this section, the term `cosmetic surgery and medical
procedure' means any cosmetic surgery (as defined in section
213(d)(9)(B)) or other similar procedure which--
``(1) is performed by a licensed medical professional, and
``(2) is not necessary to ameliorate a deformity arising
from, or directly related to, a congenital abnormality, a
personal injury resulting from an accident or trauma, or
disfiguring disease.
``(c) Payment of Tax.--
``(1) In general.--The tax imposed by this section shall be
paid by the individual on whom the procedure is performed.
``(2) Collection.--Every person receiving a payment for
procedures on which a tax is imposed under subsection (a)
shall collect the amount of the tax from the individual on
whom the procedure is performed and remit such tax quarterly
to the Secretary at such time and in such manner as provided
by the Secretary.
``(3) Secondary liability.--Where any tax imposed by
subsection (a) is not paid at the time payments for cosmetic
surgery and medical procedures are made, then to the extent
that such tax is not collected, such tax shall be paid by the
person who performs the procedure.''.
[[Page H2114]]
(b) Clerical Amendment.--The table of chapters for subtitle
D of the Internal Revenue Code of 1986, as amended by this
Act, is amended by inserting after the item relating to
chapter 48 the following new item:
``Chapter 49--Elective Cosmetic Medical Procedures''.
(c) Effective Date.--The amendments made by this section
shall apply to procedures performed on or after January 1,
2010.
Subtitle B--Other Provisions
SEC. 9021. EXCLUSION OF HEALTH BENEFITS PROVIDED BY INDIAN
TRIBAL GOVERNMENTS.
(a) In General.--Part III of subchapter B of chapter 1 of
the Internal Revenue Code of 1986 is amended by inserting
after section 139C the following new section:
``SEC. 139D. INDIAN HEALTH CARE BENEFITS.
``(a) General Rule.--Except as otherwise provided in this
section, gross income does not include the value of any
qualified Indian health care benefit.
``(b) Qualified Indian Health Care Benefit.--For purposes
of this section, the term `qualified Indian health care
benefit' means--
``(1) any health service or benefit provided or purchased,
directly or indirectly, by the Indian Health Service through
a grant to or a contract or compact with an Indian tribe or
tribal organization, or through a third-party program funded
by the Indian Health Service,
``(2) medical care provided or purchased by, or amounts to
reimburse for such medical care provided by, an Indian tribe
or tribal organization for, or to, a member of an Indian
tribe, including a spouse or dependent of such a member,
``(3) coverage under accident or health insurance (or an
arrangement having the effect of accident or health
insurance), or an accident or health plan, provided by an
Indian tribe or tribal organization for medical care to a
member of an Indian tribe, include a spouse or dependent of
such a member, and
``(4) any other medical care provided by an Indian tribe or
tribal organization that supplements, replaces, or
substitutes for a program or service relating to medical care
provided by the Federal government to Indian tribes or
members of such a tribe.
``(c) Definitions.--For purposes of this section--
``(1) Indian tribe.--The term `Indian tribe' has the
meaning given such term by section 45A(c)(6).
``(2) Tribal organization.--The term `tribal organization'
has the meaning given such term by section 4(l) of the Indian
Self-Determination and Education Assistance Act.
``(3) Medical care.--The term `medical care' has the same
meaning as when used in section 213.
``(4) Accident or health insurance; accident or health
plan.--The terms `accident or health insurance' and `accident
or health plan' have the same meaning as when used in section
105.
``(5) Dependent.--The term `dependent' has the meaning
given such term by section 152, determined without regard to
subsections (b)(1), (b)(2), and (d)(1)(B) thereof.
``(d) Denial of Double Benefit.--Subsection (a) shall not
apply to the amount of any qualified Indian health care
benefit which is not includible in gross income of the
beneficiary of such benefit under any other provision of this
chapter, or to the amount of any such benefit for which a
deduction is allowed to such beneficiary under any other
provision of this chapter.''.
(b) Clerical Amendment.--The table of sections for part III
of subchapter B of chapter 1 of the Internal Revenue Code of
1986 is amended by inserting after the item relating to
section 139C the following new item:
``Sec. 139D. Indian health care benefits.''.
(c) Effective Date.--The amendments made by this section
shall apply to benefits and coverage provided after the date
of the enactment of this Act.
(d) No Inference.--Nothing in the amendments made by this
section shall be construed to create an inference with
respect to the exclusion from gross income of--
(1) benefits provided by an Indian tribe or tribal
organization that are not within the scope of this section,
and
(2) benefits provided prior to the date of the enactment of
this Act.
SEC. 9022. ESTABLISHMENT OF SIMPLE CAFETERIA PLANS FOR SMALL
BUSINESSES.
(a) In General.--Section 125 of the Internal Revenue Code
of 1986 (relating to cafeteria plans), as amended by this
Act, is amended by redesignating subsections (j) and (k) as
subsections (k) and (l), respectively, and by inserting after
subsection (i) the following new subsection:
``(j) Simple Cafeteria Plans for Small Businesses.--
``(1) In general.--An eligible employer maintaining a
simple cafeteria plan with respect to which the requirements
of this subsection are met for any year shall be treated as
meeting any applicable nondiscrimination requirement during
such year.
``(2) Simple cafeteria plan.--For purposes of this
subsection, the term `simple cafeteria plan' means a
cafeteria plan--
``(A) which is established and maintained by an eligible
employer, and
``(B) with respect to which the contribution requirements
of paragraph (3), and the eligibility and participation
requirements of paragraph (4), are met.
``(3) Contribution requirements.--
``(A) In general.--The requirements of this paragraph are
met if, under the plan the employer is required, without
regard to whether a qualified employee makes any salary
reduction contribution, to make a contribution to provide
qualified benefits under the plan on behalf of each qualified
employee in an amount equal to--
``(i) a uniform percentage (not less than 2 percent) of the
employee's compensation for the plan year, or
``(ii) an amount which is not less than the lesser of--
``(I) 6 percent of the employee's compensation for the plan
year, or
``(II) twice the amount of the salary reduction
contributions of each qualified employee.
``(B) Matching contributions on behalf of highly
compensated and key employees.--The requirements of
subparagraph (A)(ii) shall not be treated as met if, under
the plan, the rate of contributions with respect to any
salary reduction contribution of a highly compensated or key
employee at any rate of contribution is greater than that
with respect to an employee who is not a highly compensated
or key employee.
``(C) Additional contributions.--Subject to subparagraph
(B), nothing in this paragraph shall be treated as
prohibiting an employer from making contributions to provide
qualified benefits under the plan in addition to
contributions required under subparagraph (A).
``(D) Definitions.--For purposes of this paragraph--
``(i) Salary reduction contribution.--The term `salary
reduction contribution' means, with respect to a cafeteria
plan, any amount which is contributed to the plan at the
election of the employee and which is not includible in gross
income by reason of this section.
``(ii) Qualified employee.--The term `qualified employee'
means, with respect to a cafeteria plan, any employee who is
not a highly compensated or key employee and who is eligible
to participate in the plan.
``(iii) Highly compensated employee.--The term `highly
compensated employee' has the meaning given such term by
section 414(q).
``(iv) Key employee.--The term `key employee' has the
meaning given such term by section 416(i).
``(4) Minimum eligibility and participation requirements.--
``(A) In general.--The requirements of this paragraph shall
be treated as met with respect to any year if, under the
plan--
``(i) all employees who had at least 1,000 hours of service
for the preceding plan year are eligible to participate, and
``(ii) each employee eligible to participate in the plan
may, subject to terms and conditions applicable to all
participants, elect any benefit available under the plan.
``(B) Certain employees may be excluded.--For purposes of
subparagraph (A)(i), an employer may elect to exclude under
the plan employees--
``(i) who have not attained the age of 21 before the close
of a plan year,
``(ii) who have less than 1 year of service with the
employer as of any day during the plan year,
``(iii) who are covered under an agreement which the
Secretary of Labor finds to be a collective bargaining
agreement if there is evidence that the benefits covered
under the cafeteria plan were the subject of good faith
bargaining between employee representatives and the employer,
or
``(iv) who are described in section 410(b)(3)(C) (relating
to nonresident aliens working outside the United States).
A plan may provide a shorter period of service or younger age
for purposes of clause (i) or (ii).
``(5) Eligible employer.--For purposes of this subsection--
``(A) In general.--The term `eligible employer' means, with
respect to any year, any employer if such employer employed
an average of 100 or fewer employees on business days during
either of the 2 preceding years. For purposes of this
subparagraph, a year may only be taken into account if the
employer was in existence throughout the year.
``(B) Employers not in existence during preceding year.--If
an employer was not in existence throughout the preceding
year, the determination under subparagraph (A) shall be based
on the average number of employees that it is reasonably
expected such employer will employ on business days in the
current year.
``(C) Growing employers retain treatment as small
employer.--
``(i) In general.--If--
``(I) an employer was an eligible employer for any year (a
`qualified year'), and
``(II) such employer establishes a simple cafeteria plan
for its employees for such year,
then, notwithstanding the fact the employer fails to meet the
requirements of subparagraph (A) for any subsequent year,
such employer shall be treated as an eligible employer for
such subsequent year with respect to employees (whether or
not employees during a qualified year) of any trade or
business which was covered by the plan during any qualified
year.
``(ii) Exception.--This subparagraph shall cease to apply
if the employer employs an average of 200 or more employees
on business days during any year preceding any such
subsequent year.
``(D) Special rules.--
``(i) Predecessors.--Any reference in this paragraph to an
employer shall include a reference to any predecessor of such
employer.
``(ii) Aggregation rules.--All persons treated as a single
employer under subsection (a) or (b) of section 52, or
subsection (n) or (o) of section 414, shall be treated as one
person.
``(6) Applicable nondiscrimination requirement.--For
purposes of this subsection, the term `applicable
nondiscrimination requirement' means any requirement under
subsection (b) of this section, section 79(d), section
105(h), or paragraph (2), (3), (4), or (8) of section 129(d).
[[Page H2115]]
``(7) Compensation.--The term `compensation' has the
meaning given such term by section 414(s).''.
(b) Effective Date.--The amendments made by this section
shall apply to years beginning after December 31, 2010.
SEC. 9023. QUALIFYING THERAPEUTIC DISCOVERY PROJECT CREDIT.
(a) In General.--Subpart E of part IV of subchapter A of
chapter 1 of the Internal Revenue Code of 1986 is amended by
inserting after section 48C the following new section:
``SEC. 48D. QUALIFYING THERAPEUTIC DISCOVERY PROJECT CREDIT.
``(a) In General.--For purposes of section 46, the
qualifying therapeutic discovery project credit for any
taxable year is an amount equal to 50 percent of the
qualified investment for such taxable year with respect to
any qualifying therapeutic discovery project of an eligible
taxpayer.
``(b) Qualified Investment.--
``(1) In general.--For purposes of subsection (a), the
qualified investment for any taxable year is the aggregate
amount of the costs paid or incurred in such taxable year for
expenses necessary for and directly related to the conduct of
a qualifying therapeutic discovery project.
``(2) Limitation.--The amount which is treated as qualified
investment for all taxable years with respect to any
qualifying therapeutic discovery project shall not exceed the
amount certified by the Secretary as eligible for the credit
under this section.
``(3) Exclusions.--The qualified investment for any taxable
year with respect to any qualifying therapeutic discovery
project shall not take into account any cost--
``(A) for remuneration for an employee described in section
162(m)(3),
``(B) for interest expenses,
``(C) for facility maintenance expenses,
``(D) which is identified as a service cost under section
1.263A-1(e)(4) of title 26, Code of Federal Regulations, or
``(E) for any other expense as determined by the Secretary
as appropriate to carry out the purposes of this section.
``(4) Certain progress expenditure rules made applicable.--
In the case of costs described in paragraph (1) that are paid
for property of a character subject to an allowance for
depreciation, rules similar to the rules of subsections
(c)(4) and (d) of section 46 (as in effect on the day before
the date of the enactment of the Revenue Reconciliation Act
of 1990) shall apply for purposes of this section.
``(5) Application of subsection.--An investment shall be
considered a qualified investment under this subsection only
if such investment is made in a taxable year beginning in
2009 or 2010.
``(c) Definitions.--
``(1) Qualifying therapeutic discovery project.--The term
`qualifying therapeutic discovery project' means a project
which is designed--
``(A) to treat or prevent diseases or conditions by
conducting pre-clinical activities, clinical trials, and
clinical studies, or carrying out research protocols, for the
purpose of securing approval of a product under section
505(b) of the Federal Food, Drug, and Cosmetic Act or section
351(a) of the Public Health Service Act,
``(B) to diagnose diseases or conditions or to determine
molecular factors related to diseases or conditions by
developing molecular diagnostics to guide therapeutic
decisions, or
``(C) to develop a product, process, or technology to
further the delivery or administration of therapeutics.
``(2) Eligible taxpayer.--
``(A) In general.--The term `eligible taxpayer' means a
taxpayer which employs not more than 250 employees in all
businesses of the taxpayer at the time of the submission of
the application under subsection (d)(2).
``(B) Aggregation rules.--All persons treated as a single
employer under subsection (a) or (b) of section 52, or
subsection (m) or (o) of section 414, shall be so treated for
purposes of this paragraph.
``(3) Facility maintenance expenses.--The term `facility
maintenance expenses' means costs paid or incurred to
maintain a facility, including--
``(A) mortgage or rent payments,
``(B) insurance payments,
``(C) utility and maintenance costs, and
``(D) costs of employment of maintenance personnel.
``(d) Qualifying Therapeutic Discovery Project Program.--
``(1) Establishment.--
``(A) In general.--Not later than 60 days after the date of
the enactment of this section, the Secretary, in consultation
with the Secretary of Health and Human Services, shall
establish a qualifying therapeutic discovery project program
to consider and award certifications for qualified
investments eligible for credits under this section to
qualifying therapeutic discovery project sponsors.
``(B) Limitation.--The total amount of credits that may be
allocated under the program shall not exceed $1,000,000,000
for the 2-year period beginning with 2009.
``(2) Certification.--
``(A) Application period.--Each applicant for certification
under this paragraph shall submit an application containing
such information as the Secretary may require during the
period beginning on the date the Secretary establishes the
program under paragraph (1).
``(B) Time for review of applications.--The Secretary shall
take action to approve or deny any application under
subparagraph (A) within 30 days of the submission of such
application.
``(C) Multi-year applications.--An application for
certification under subparagraph (A) may include a request
for an allocation of credits for more than 1 of the years
described in paragraph (1)(B).
``(3) Selection criteria.--In determining the qualifying
therapeutic discovery projects with respect to which
qualified investments may be certified under this section,
the Secretary--
``(A) shall take into consideration only those projects
that show reasonable potential--
``(i) to result in new therapies--
``(I) to treat areas of unmet medical need, or
``(II) to prevent, detect, or treat chronic or acute
diseases and conditions,
``(ii) to reduce long-term health care costs in the United
States, or
``(iii) to significantly advance the goal of curing cancer
within the 30-year period beginning on the date the Secretary
establishes the program under paragraph (1), and
``(B) shall take into consideration which projects have the
greatest potential--
``(i) to create and sustain (directly or indirectly) high
quality, high-paying jobs in the United States, and
``(ii) to advance United States competitiveness in the
fields of life, biological, and medical sciences.
``(4) Disclosure of allocations.--The Secretary shall, upon
making a certification under this subsection, publicly
disclose the identity of the applicant and the amount of the
credit with respect to such applicant.
``(e) Special Rules.--
``(1) Basis adjustment.--For purposes of this subtitle, if
a credit is allowed under this section for an expenditure
related to property of a character subject to an allowance
for depreciation, the basis of such property shall be reduced
by the amount of such credit.
``(2) Denial of double benefit.--
``(A) Bonus depreciation.--A credit shall not be allowed
under this section for any investment for which bonus
depreciation is allowed under section 168(k), 1400L(b)(1), or
1400N(d)(1).
``(B) Deductions.--No deduction under this subtitle shall
be allowed for the portion of the expenses otherwise
allowable as a deduction taken into account in determining
the credit under this section for the taxable year which is
equal to the amount of the credit determined for such taxable
year under subsection (a) attributable to such portion. This
subparagraph shall not apply to expenses related to property
of a character subject to an allowance for depreciation the
basis of which is reduced under paragraph (1), or which are
described in section 280C(g).
``(C) Credit for research activities.--
``(i) In general.--Except as provided in clause (ii), any
expenses taken into account under this section for a taxable
year shall not be taken into account for purposes of
determining the credit allowable under section 41 or 45C for
such taxable year.
``(ii) Expenses included in determining base period
research expenses.--Any expenses for any taxable year which
are qualified research expenses (within the meaning of
section 41(b)) shall be taken into account in determining
base period research expenses for purposes of applying
section 41 to subsequent taxable years.
``(f) Coordination With Department of Treasury Grants.--In
the case of any investment with respect to which the
Secretary makes a grant under section 9023(e) of the Patient
Protection and Affordable Care Act of 2009--
``(1) Denial of credit.--No credit shall be determined
under this section with respect to such investment for the
taxable year in which such grant is made or any subsequent
taxable year.
``(2) Recapture of credits for progress expenditures made
before grant.--If a credit was determined under this section
with respect to such investment for any taxable year ending
before such grant is made--
``(A) the tax imposed under subtitle A on the taxpayer for
the taxable year in which such grant is made shall be
increased by so much of such credit as was allowed under
section 38,
``(B) the general business carryforwards under section 39
shall be adjusted so as to recapture the portion of such
credit which was not so allowed, and
``(C) the amount of such grant shall be determined without
regard to any reduction in the basis of any property of a
character subject to an allowance for depreciation by reason
of such credit.
``(3) Treatment of grants.--Any such grant shall not be
includible in the gross income of the taxpayer.''.
(b) Inclusion as Part of Investment Credit.--Section 46 of
the Internal Revenue Code of 1986 is amended--
(1) by adding a comma at the end of paragraph (2),
(2) by striking the period at the end of paragraph (5) and
inserting ``, and'', and
(3) by adding at the end the following new paragraph:
``(6) the qualifying therapeutic discovery project
credit.''.
(c) Conforming Amendments.--
(1) Section 49(a)(1)(C) of the Internal Revenue Code of
1986 is amended--
(A) by striking ``and'' at the end of clause (iv),
(B) by striking the period at the end of clause (v) and
inserting ``, and'', and
(C) by adding at the end the following new clause:
``(vi) the basis of any property to which paragraph (1) of
section 48D(e) applies which is part of a qualifying
therapeutic discovery project under such section 48D.''.
(2) Section 280C of such Code is amended by adding at the
end the following new subsection:
``(g) Qualifying Therapeutic Discovery Project Credit.--
``(1) In general.--No deduction shall be allowed for that
portion of the qualified investment (as defined in section
48D(b)) otherwise allowable as a deduction for the taxable
year which--
[[Page H2116]]
``(A) would be qualified research expenses (as defined in
section 41(b)), basic research expenses (as defined in
section 41(e)(2)), or qualified clinical testing expenses (as
defined in section 45C(b)) if the credit under section 41 or
section 45C were allowed with respect to such expenses for
such taxable year, and
``(B) is equal to the amount of the credit determined for
such taxable year under section 48D(a), reduced by--
``(i) the amount disallowed as a deduction by reason of
section 48D(e)(2)(B), and
``(ii) the amount of any basis reduction under section
48D(e)(1).
``(2) Similar rule where taxpayer capitalizes rather than
deducts expenses.--In the case of expenses described in
paragraph (1)(A) taken into account in determining the credit
under section 48D for the taxable year, if--
``(A) the amount of the portion of the credit determined
under such section with respect to such expenses, exceeds
``(B) the amount allowable as a deduction for such taxable
year for such expenses (determined without regard to
paragraph (1)),
the amount chargeable to capital account for the taxable year
for such expenses shall be reduced by the amount of such
excess.
``(3) Controlled groups.--Paragraph (3) of subsection (b)
shall apply for purposes of this subsection.''.
(d) Clerical Amendment.--The table of sections for subpart
E of part IV of subchapter A of chapter 1 of the Internal
Revenue Code of 1986 is amended by inserting after the item
relating to section 48C the following new item:
``Sec. 48D. Qualifying therapeutic discovery project credit.''.
(e) Grants for Qualified Investments in Therapeutic
Discovery Projects in Lieu of Tax Credits.--
(1) In general.--Upon application, the Secretary of the
Treasury shall, subject to the requirements of this
subsection, provide a grant to each person who makes a
qualified investment in a qualifying therapeutic discovery
project in the amount of 50 percent of such investment. No
grant shall be made under this subsection with respect to any
investment unless such investment is made during a taxable
year beginning in 2009 or 2010.
(2) Application.--
(A) In general.--At the stated election of the applicant,
an application for certification under section 48D(d)(2) of
the Internal Revenue Code of 1986 for a credit under such
section for the taxable year of the applicant which begins in
2009 shall be considered to be an application for a grant
under paragraph (1) for such taxable year.
(B) Taxable years beginning in 2010.--An application for a
grant under paragraph (1) for a taxable year beginning in
2010 shall be submitted--
(i) not earlier than the day after the last day of such
taxable year, and
(ii) not later than the due date (including extensions) for
filing the return of tax for such taxable year.
(C) Information to be submitted.--An application for a
grant under paragraph (1) shall include such information and
be in such form as the Secretary may require to state the
amount of the credit allowable (but for the receipt of a
grant under this subsection) under section 48D for the
taxable year for the qualified investment with respect to
which such application is made.
(3) Time for payment of grant.--
(A) In general.--The Secretary of the Treasury shall make
payment of the amount of any grant under paragraph (1) during
the 30-day period beginning on the later of--
(i) the date of the application for such grant, or
(ii) the date the qualified investment for which the grant
is being made is made.
(B) Regulations.--In the case of investments of an ongoing
nature, the Secretary shall issue regulations to determine
the date on which a qualified investment shall be deemed to
have been made for purposes of this paragraph.
(4) Qualified investment.--For purposes of this subsection,
the term ``qualified investment'' means a qualified
investment that is certified under section 48D(d) of the
Internal Revenue Code of 1986 for purposes of the credit
under such section 48D.
(5) Application of certain rules.--
(A) In general.--In making grants under this subsection,
the Secretary of the Treasury shall apply rules similar to
the rules of section 50 of the Internal Revenue Code of 1986.
In applying such rules, any increase in tax under chapter 1
of such Code by reason of an investment ceasing to be a
qualified investment shall be imposed on the person to whom
the grant was made.
(B) Special rules.--
(i) Recapture of excessive grant amounts.--If the amount of
a grant made under this subsection exceeds the amount
allowable as a grant under this subsection, such excess shall
be recaptured under subparagraph (A) as if the investment to
which such excess portion of the grant relates had ceased to
be a qualified investment immediately after such grant was
made.
(ii) Grant information not treated as return information.--
In no event shall the amount of a grant made under paragraph
(1), the identity of the person to whom such grant was made,
or a description of the investment with respect to which such
grant was made be treated as return information for purposes
of section 6103 of the Internal Revenue Code of 1986.
(6) Exception for certain non-taxpayers.--The Secretary of
the Treasury shall not make any grant under this subsection
to--
(A) any Federal, State, or local government (or any
political subdivision, agency, or instrumentality thereof),
(B) any organization described in section 501(c) of the
Internal Revenue Code of 1986 and exempt from tax under
section 501(a) of such Code,
(C) any entity referred to in paragraph (4) of section
54(j) of such Code, or
(D) any partnership or other pass-thru entity any partner
(or other holder of an equity or profits interest) of which
is described in subparagraph (A), (B) or (C).
In the case of a partnership or other pass-thru entity
described in subparagraph (D), partners and other holders of
any equity or profits interest shall provide to such
partnership or entity such information as the Secretary of
the Treasury may require to carry out the purposes of this
paragraph.
(7) Secretary.--Any reference in this subsection to the
Secretary of the Treasury shall be treated as including the
Secretary's delegate.
(8) Other terms.--Any term used in this subsection which is
also used in section 48D of the Internal Revenue Code of 1986
shall have the same meaning for purposes of this subsection
as when used in such section.
(9) Denial of double benefit.--No credit shall be allowed
under section 46(6) of the Internal Revenue Code of 1986 by
reason of section 48D of such Code for any investment for
which a grant is awarded under this subsection.
(10) Appropriations.--There is hereby appropriated to the
Secretary of the Treasury such sums as may be necessary to
carry out this subsection.
(11) Termination.--The Secretary of the Treasury shall not
make any grant to any person under this subsection unless the
application of such person for such grant is received before
January 1, 2013.
(12) Protecting middle class families from tax increases.--
It is the sense of the Senate that the Senate should reject
any procedural maneuver that would raise taxes on middle
class families, such as a motion to commit the pending
legislation to the Committee on Finance, which is designed to
kill legislation that provides tax cuts for American workers
and families, including the affordability tax credit and the
small business tax credit.
(f) Effective Date.--The amendments made by subsections (a)
through (d) of this section shall apply to amounts paid or
incurred after December 31, 2008, in taxable years beginning
after such date.
TITLE X--STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL
AMERICANS
Subtitle A--Provisions Relating to Title I
SEC. 10101. AMENDMENTS TO SUBTITLE A.
(a) Section 2711 of the Public Health Service Act, as added
by section 1001(5) of this Act, is amended to read as
follows:
``SEC. 2711. NO LIFETIME OR ANNUAL LIMITS.
``(a) Prohibition.--
``(1) In general.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage may not establish--
``(A) lifetime limits on the dollar value of benefits for
any participant or beneficiary; or
``(B) except as provided in paragraph (2), annual limits on
the dollar value of benefits for any participant or
beneficiary.
``(2) Annual limits prior to 2014.--With respect to plan
years beginning prior to January 1, 2014, a group health plan
and a health insurance issuer offering group or individual
health insurance coverage may only establish a restricted
annual limit on the dollar value of benefits for any
participant or beneficiary with respect to the scope of
benefits that are essential health benefits under section
1302(b) of the Patient Protection and Affordable Care Act, as
determined by the Secretary. In defining the term `restricted
annual limit' for purposes of the preceding sentence, the
Secretary shall ensure that access to needed services is made
available with a minimal impact on premiums.
``(b) Per Beneficiary Limits.--Subsection (a) shall not be
construed to prevent a group health plan or health insurance
coverage from placing annual or lifetime per beneficiary
limits on specific covered benefits that are not essential
health benefits under section 1302(b) of the Patient
Protection and Affordable Care Act, to the extent that such
limits are otherwise permitted under Federal or State law.''.
(b) Section 2715(a) of the Public Health Service Act, as
added by section 1001(5) of this Act, is amended by striking
``and providing to enrollees'' and inserting ``and providing
to applicants, enrollees, and policyholders or certificate
holders''.
(c) Subpart II of part A of title XXVII of the Public
Health Service Act, as added by section 1001(5), is amended
by inserting after section 2715, the following:
``SEC. 2715A. PROVISION OF ADDITIONAL INFORMATION.
``A group health plan and a health insurance issuer
offering group or individual health insurance coverage shall
comply with the provisions of section 1311(e)(3) of the
Patient Protection and Affordable Care Act, except that a
plan or coverage that is not offered through an Exchange
shall only be required to submit the information required to
the Secretary and the State insurance commissioner, and make
such information available to the public.''.
(d) Section 2716 of the Public Health Service Act, as added
by section 1001(5) of this Act, is amended to read as
follows:
``SEC. 2716. PROHIBITION ON DISCRIMINATION IN FAVOR OF HIGHLY
COMPENSATED INDIVIDUALS.
``(a) In General.--A group health plan (other than a self-
insured plan) shall satisfy the requirements of section
105(h)(2) of the Internal Revenue Code of 1986 (relating to
prohibition on discrimination in favor of highly compensated
individuals).
[[Page H2117]]
``(b) Rules and Definitions.--For purposes of this
section--
``(1) Certain rules to apply.--Rules similar to the rules
contained in paragraphs (3), (4), and (8) of section 105(h)
of such Code shall apply.
``(2) Highly compensated individual.--The term `highly
compensated individual' has the meaning given such term by
section 105(h)(5) of such Code.''.
(e) Section 2717 of the Public Health Service Act, as added
by section 1001(5) of this Act, is amended--
(1) by redesignating subsections (c) and (d) as subsections
(d) and (e), respectively; and
(2) by inserting after subsection (b), the following:
``(c) Protection of Second Amendment Gun Rights.--
``(1) Wellness and prevention programs.--A wellness and
health promotion activity implemented under subsection
(a)(1)(D) may not require the disclosure or collection of any
information relating to--
``(A) the presence or storage of a lawfully-possessed
firearm or ammunition in the residence or on the property of
an individual; or
``(B) the lawful use, possession, or storage of a firearm
or ammunition by an individual.
``(2) Limitation on data collection.--None of the
authorities provided to the Secretary under the Patient
Protection and Affordable Care Act or an amendment made by
that Act shall be construed to authorize or may be used for
the collection of any information relating to--
``(A) the lawful ownership or possession of a firearm or
ammunition;
``(B) the lawful use of a firearm or ammunition; or
``(C) the lawful storage of a firearm or ammunition.
``(3) Limitation on databases or data banks.--None of the
authorities provided to the Secretary under the Patient
Protection and Affordable Care Act or an amendment made by
that Act shall be construed to authorize or may be used to
maintain records of individual ownership or possession of a
firearm or ammunition.
``(4) Limitation on determination of premium rates or
eligibility for health insurance.--A premium rate may not be
increased, health insurance coverage may not be denied, and a
discount, rebate, or reward offered for participation in a
wellness program may not be reduced or withheld under any
health benefit plan issued pursuant to or in accordance with
the Patient Protection and Affordable Care Act or an
amendment made by that Act on the basis of, or on reliance
upon--
``(A) the lawful ownership or possession of a firearm or
ammunition; or
``(B) the lawful use or storage of a firearm or ammunition.
``(5) Limitation on data collection requirements for
individuals.--No individual shall be required to disclose any
information under any data collection activity authorized
under the Patient Protection and Affordable Care Act or an
amendment made by that Act relating to--
``(A) the lawful ownership or possession of a firearm or
ammunition; or
``(B) the lawful use, possession, or storage of a firearm
or ammunition.''.
(f) Section 2718 of the Public Health Service Act, as added
by section 1001(5), is amended to read as follows:
``SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE COVERAGE.
``(a) Clear Accounting for Costs.--A health insurance
issuer offering group or individual health insurance coverage
(including a grandfathered health plan) shall, with respect
to each plan year, submit to the Secretary a report
concerning the ratio of the incurred loss (or incurred
claims) plus the loss adjustment expense (or change in
contract reserves) to earned premiums. Such report shall
include the percentage of total premium revenue, after
accounting for collections or receipts for risk adjustment
and risk corridors and payments of reinsurance, that such
coverage expends--
``(1) on reimbursement for clinical services provided to
enrollees under such coverage;
``(2) for activities that improve health care quality; and
``(3) on all other non-claims costs, including an
explanation of the nature of such costs, and excluding
Federal and State taxes and licensing or regulatory fees.
The Secretary shall make reports received under this section
available to the public on the Internet website of the
Department of Health and Human Services.
``(b) Ensuring That Consumers Receive Value for Their
Premium Payments.--
``(1) Requirement to provide value for premium payments.--
``(A) Requirement.--Beginning not later than January 1,
2011, a health insurance issuer offering group or individual
health insurance coverage (including a grandfathered health
plan) shall, with respect to each plan year, provide an
annual rebate to each enrollee under such coverage, on a pro
rata basis, if the ratio of the amount of premium revenue
expended by the issuer on costs described in paragraphs (1)
and (2) of subsection (a) to the total amount of premium
revenue (excluding Federal and State taxes and licensing or
regulatory fees and after accounting for payments or receipts
for risk adjustment, risk corridors, and reinsurance under
sections 1341, 1342, and 1343 of the Patient Protection and
Affordable Care Act) for the plan year (except as provided in
subparagraph (B)(ii)), is less than--
``(i) with respect to a health insurance issuer offering
coverage in the large group market, 85 percent, or such
higher percentage as a State may by regulation determine; or
``(ii) with respect to a health insurance issuer offering
coverage in the small group market or in the individual
market, 80 percent, or such higher percentage as a State may
by regulation determine, except that the Secretary may adjust
such percentage with respect to a State if the Secretary
determines that the application of such 80 percent may
destabilize the individual market in such State.
``(B) Rebate amount.--
``(i) Calculation of amount.--The total amount of an annual
rebate required under this paragraph shall be in an amount
equal to the product of--
``(I) the amount by which the percentage described in
clause (i) or (ii) of subparagraph (A) exceeds the ratio
described in such subparagraph; and
``(II) the total amount of premium revenue (excluding
Federal and State taxes and licensing or regulatory fees and
after accounting for payments or receipts for risk
adjustment, risk corridors, and reinsurance under sections
1341, 1342, and 1343 of the Patient Protection and Affordable
Care Act) for such plan year.
``(ii) Calculation based on average ratio.--Beginning on
January 1, 2014, the determination made under subparagraph
(A) for the year involved shall be based on the averages of
the premiums expended on the costs described in such
subparagraph and total premium revenue for each of the
previous 3 years for the plan.
``(2) Consideration in setting percentages.--In determining
the percentages under paragraph (1), a State shall seek to
ensure adequate participation by health insurance issuers,
competition in the health insurance market in the State, and
value for consumers so that premiums are used for clinical
services and quality improvements.
``(3) Enforcement.--The Secretary shall promulgate
regulations for enforcing the provisions of this section and
may provide for appropriate penalties.
``(c) Definitions.--Not later than December 31, 2010, and
subject to the certification of the Secretary, the National
Association of Insurance Commissioners shall establish
uniform definitions of the activities reported under
subsection (a) and standardized methodologies for calculating
measures of such activities, including definitions of which
activities, and in what regard such activities, constitute
activities described in subsection (a)(2). Such methodologies
shall be designed to take into account the special
circumstances of smaller plans, different types of plans, and
newer plans.
``(d) Adjustments.--The Secretary may adjust the rates
described in subsection (b) if the Secretary determines
appropriate on account of the volatility of the individual
market due to the establishment of State Exchanges.
``(e) Standard Hospital Charges.--Each hospital operating
within the United States shall for each year establish (and
update) and make public (in accordance with guidelines
developed by the Secretary) a list of the hospital's standard
charges for items and services provided by the hospital,
including for diagnosis-related groups established under
section 1886(d)(4) of the Social Security Act.''.
(g) Section 2719 of the Public Health Service Act, as added
by section 1001(4) of this Act, is amended to read as
follows:
``SEC. 2719. APPEALS PROCESS.
``(a) Internal Claims Appeals.--
``(1) In general.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage shall implement an effective appeals
process for appeals of coverage determinations and claims,
under which the plan or issuer shall, at a minimum--
``(A) have in effect an internal claims appeal process;
``(B) provide notice to enrollees, in a culturally and
linguistically appropriate manner, of available internal and
external appeals processes, and the availability of any
applicable office of health insurance consumer assistance or
ombudsman established under section 2793 to assist such
enrollees with the appeals processes; and
``(C) allow an enrollee to review their file, to present
evidence and testimony as part of the appeals process, and to
receive continued coverage pending the outcome of the appeals
process.
``(2) Established processes.--To comply with paragraph
(1)--
``(A) a group health plan and a health insurance issuer
offering group health coverage shall provide an internal
claims and appeals process that initially incorporates the
claims and appeals procedures (including urgent claims) set
forth at section 2560.503-1 of title 29, Code of Federal
Regulations, as published on November 21, 2000 (65 Fed. Reg.
70256), and shall update such process in accordance with any
standards established by the Secretary of Labor for such
plans and issuers; and
``(B) a health insurance issuer offering individual health
coverage, and any other issuer not subject to subparagraph
(A), shall provide an internal claims and appeals process
that initially incorporates the claims and appeals procedures
set forth under applicable law (as in existence on the date
of enactment of this section), and shall update such process
in accordance with any standards established by the Secretary
of Health and Human Services for such issuers.
``(b) External Review.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage--
``(1) shall comply with the applicable State external
review process for such plans and issuers that, at a minimum,
includes the consumer protections set forth in the Uniform
External Review Model Act promulgated by the National
Association of Insurance Commissioners and is binding on such
plans; or
``(2) shall implement an effective external review process
that meets minimum standards established by the Secretary
through guidance
[[Page H2118]]
and that is similar to the process described under paragraph
(1)--
``(A) if the applicable State has not established an
external review process that meets the requirements of
paragraph (1); or
``(B) if the plan is a self-insured plan that is not
subject to State insurance regulation (including a State law
that establishes an external review process described in
paragraph (1)).
``(c) Secretary Authority.--The Secretary may deem the
external review process of a group health plan or health
insurance issuer, in operation as of the date of enactment of
this section, to be in compliance with the applicable process
established under subsection (b), as determined appropriate
by the Secretary.''.
(h) Subpart II of part A of title XVIII of the Public
Health Service Act, as added by section 1001(5) of this Act,
is amended by inserting after section 2719 the following:
``SEC. 2719A. PATIENT PROTECTIONS.
``(a) Choice of Health Care Professional.--If a group
health plan, or a health insurance issuer offering group or
individual health insurance coverage, requires or provides
for designation by a participant, beneficiary, or enrollee of
a participating primary care provider, then the plan or
issuer shall permit each participant, beneficiary, and
enrollee to designate any participating primary care provider
who is available to accept such individual.
``(b) Coverage of Emergency Services.--
``(1) In general.--If a group health plan, or a health
insurance issuer offering group or individual health
insurance issuer, provides or covers any benefits with
respect to services in an emergency department of a hospital,
the plan or issuer shall cover emergency services (as defined
in paragraph (2)(B))--
``(A) without the need for any prior authorization
determination;
``(B) whether the health care provider furnishing such
services is a participating provider with respect to such
services;
``(C) in a manner so that, if such services are provided to
a participant, beneficiary, or enrollee--
``(i) by a nonparticipating health care provider with or
without prior authorization; or
``(ii)(I) such services will be provided without imposing
any requirement under the plan for prior authorization of
services or any limitation on coverage where the provider of
services does not have a contractual relationship with the
plan for the providing of services that is more restrictive
than the requirements or limitations that apply to emergency
department services received from providers who do have such
a contractual relationship with the plan; and
``(II) if such services are provided out-of-network, the
cost-sharing requirement (expressed as a copayment amount or
coinsurance rate) is the same requirement that would apply if
such services were provided in-network;
``(D) without regard to any other term or condition of such
coverage (other than exclusion or coordination of benefits,
or an affiliation or waiting period, permitted under section
2701 of this Act, section 701 of the Employee Retirement
Income Security Act of 1974, or section 9801 of the Internal
Revenue Code of 1986, and other than applicable cost-
sharing).
``(2) Definitions.--In this subsection:
``(A) Emergency medical condition.--The term `emergency
medical condition' means a medical condition manifesting
itself by acute symptoms of sufficient severity (including
severe pain) such that a prudent layperson, who possesses an
average knowledge of health and medicine, could reasonably
expect the absence of immediate medical attention to result
in a condition described in clause (i), (ii), or (iii) of
section 1867(e)(1)(A) of the Social Security Act.
``(B) Emergency services.--The term `emergency services'
means, with respect to an emergency medical condition--
``(i) a medical screening examination (as required under
section 1867 of the Social Security Act) that is within the
capability of the emergency department of a hospital,
including ancillary services routinely available to the
emergency department to evaluate such emergency medical
condition, and
``(ii) within the capabilities of the staff and facilities
available at the hospital, such further medical examination
and treatment as are required under section 1867 of such Act
to stabilize the patient.
``(C) Stabilize.--The term `to stabilize', with respect to
an emergency medical condition (as defined in subparagraph
(A)), has the meaning give in section 1867(e)(3) of the
Social Security Act (42 U.S.C. 1395dd(e)(3)).
``(c) Access to Pediatric Care.--
``(1) Pediatric care.--In the case of a person who has a
child who is a participant, beneficiary, or enrollee under a
group health plan, or health insurance coverage offered by a
health insurance issuer in the group or individual market, if
the plan or issuer requires or provides for the designation
of a participating primary care provider for the child, the
plan or issuer shall permit such person to designate a
physician (allopathic or osteopathic) who specializes in
pediatrics as the child's primary care provider if such
provider participates in the network of the plan or issuer.
``(2) Construction.--Nothing in paragraph (1) shall be
construed to waive any exclusions of coverage under the terms
and conditions of the plan or health insurance coverage with
respect to coverage of pediatric care.
``(d) Patient Access to Obstetrical and Gynecological
Care.--
``(1) General rights.--
``(A) Direct access.--A group health plan, or health
insurance issuer offering group or individual health
insurance coverage, described in paragraph (2) may not
require authorization or referral by the plan, issuer, or any
person (including a primary care provider described in
paragraph (2)(B)) in the case of a female participant,
beneficiary, or enrollee who seeks coverage for obstetrical
or gynecological care provided by a participating health care
professional who specializes in obstetrics or gynecology.
Such professional shall agree to otherwise adhere to such
plan's or issuer's policies and procedures, including
procedures regarding referrals and obtaining prior
authorization and providing services pursuant to a treatment
plan (if any) approved by the plan or issuer.
``(B) Obstetrical and gynecological care.--A group health
plan or health insurance issuer described in paragraph (2)
shall treat the provision of obstetrical and gynecological
care, and the ordering of related obstetrical and
gynecological items and services, pursuant to the direct
access described under subparagraph (A), by a participating
health care professional who specializes in obstetrics or
gynecology as the authorization of the primary care provider.
``(2) Application of paragraph.--A group health plan, or
health insurance issuer offering group or individual health
insurance coverage, described in this paragraph is a group
health plan or coverage that--
``(A) provides coverage for obstetric or gynecologic care;
and
``(B) requires the designation by a participant,
beneficiary, or enrollee of a participating primary care
provider.
``(3) Construction.--Nothing in paragraph (1) shall be
construed to--
``(A) waive any exclusions of coverage under the terms and
conditions of the plan or health insurance coverage with
respect to coverage of obstetrical or gynecological care; or
``(B) preclude the group health plan or health insurance
issuer involved from requiring that the obstetrical or
gynecological provider notify the primary care health care
professional or the plan or issuer of treatment decisions.''.
(i) Section 2794 of the Public Health Service Act, as added
by section 1003 of this Act, is amended--
(1) in subsection (c)(1)--
(A) in subparagraph (A), by striking ``and'' at the end;
(B) in subparagraph (B), by striking the period and
inserting ``; and''; and
(C) by adding at the end the following:
``(C) in establishing centers (consistent with subsection
(d)) at academic or other nonprofit institutions to collect
medical reimbursement information from health insurance
issuers, to analyze and organize such information, and to
make such information available to such issuers, health care
providers, health researchers, health care policy makers, and
the general public.''; and
(2) by adding at the end the following:
``(d) Medical Reimbursement Data Centers.--
``(1) Functions.--A center established under subsection
(c)(1)(C) shall--
``(A) develop fee schedules and other database tools that
fairly and accurately reflect market rates for medical
services and the geographic differences in those rates;
``(B) use the best available statistical methods and data
processing technology to develop such fee schedules and other
database tools;
``(C) regularly update such fee schedules and other
database tools to reflect changes in charges for medical
services;
``(D) make health care cost information readily available
to the public through an Internet website that allows
consumers to understand the amounts that health care
providers in their area charge for particular medical
services; and
``(E) regularly publish information concerning the
statistical methodologies used by the center to analyze
health charge data and make such data available to
researchers and policy makers.
``(2) Conflicts of interest.--A center established under
subsection (c)(1)(C) shall adopt by-laws that ensures that
the center (and all members of the governing board of the
center) is independent and free from all conflicts of
interest. Such by-laws shall ensure that the center is not
controlled or influenced by, and does not have any corporate
relation to, any individual or entity that may make or
receive payments for health care services based on the
center's analysis of health care costs.
``(3) Rule of construction.--Nothing in this subsection
shall be construed to permit a center established under
subsection (c)(1)(C) to compel health insurance issuers to
provide data to the center.''.
SEC. 10102. AMENDMENTS TO SUBTITLE B.
(a) Section 1102(a)(2)(B) of this Act is amended--
(1) in the matter preceding clause (i), by striking ``group
health benefits plan'' and inserting ``group benefits plan
providing health benefits''; and
(2) in clause (i)(I), by inserting ``or any agency or
instrumentality of any of the foregoing'' before the closed
parenthetical.
(b) Section 1103(a) of this Act is amended--
(1) in paragraph (1), by inserting ``, or small business
in,'' after ``residents of any''; and
(2) by striking paragraph (2) and inserting the following:
``(2) Connecting to affordable coverage.--An Internet
website established under paragraph (1) shall, to the extent
practicable, provide ways for residents of, and small
businesses in, any State to receive information on at least
the following coverage options:
``(A) Health insurance coverage offered by health insurance
issuers, other than coverage that provides reimbursement only
for the treatment or mitigation of--
``(i) a single disease or condition; or
``(ii) an unreasonably limited set of diseases or
conditions (as determined by the Secretary).
``(B) Medicaid coverage under title XIX of the Social
Security Act.
``(C) Coverage under title XXI of the Social Security Act.
[[Page H2119]]
``(D) A State health benefits high risk pool, to the extent
that such high risk pool is offered in such State; and
``(E) Coverage under a high risk pool under section 1101.
``(F) Coverage within the small group market for small
businesses and their employees, including reinsurance for
early retirees under section 1102, tax credits available
under section 45R of the Internal Revenue Code of 1986 (as
added by section 1421), and other information specifically
for small businesses regarding affordable health care
options.''.
SEC. 10103. AMENDMENTS TO SUBTITLE C.
(a) Section 2701(a)(5) of the Public Health Service Act, as
added by section 1201(4) of this Act, is amended by inserting
``(other than self-insured group health plans offered in such
market)'' after ``such market''.
(b) Section 2708 of the Public Health Service Act, as added
by section 1201(4) of this Act, is amended by striking ``or
individual''.
(c) Subpart I of part A of title XXVII of the Public Health
Service Act, as added by section 1201(4) of this Act, is
amended by inserting after section 2708, the following:
``SEC. 2709. COVERAGE FOR INDIVIDUALS PARTICIPATING IN
APPROVED CLINICAL TRIALS.
``(a) Coverage.--
``(1) In general.--If a group health plan or a health
insurance issuer offering group or individual health
insurance coverage provides coverage to a qualified
individual, then such plan or issuer--
``(A) may not deny the individual participation in the
clinical trial referred to in subsection (b)(2);
``(B) subject to subsection (c), may not deny (or limit or
impose additional conditions on) the coverage of routine
patient costs for items and services furnished in connection
with participation in the trial; and
``(C) may not discriminate against the individual on the
basis of the individual's participation in such trial.
``(2) Routine patient costs.--
``(A) Inclusion.--For purposes of paragraph (1)(B), subject
to subparagraph (B), routine patient costs include all items
and services consistent with the coverage provided in the
plan (or coverage) that is typically covered for a qualified
individual who is not enrolled in a clinical trial.
``(B) Exclusion.--For purposes of paragraph (1)(B), routine
patient costs does not include--
``(i) the investigational item, device, or service, itself;
``(ii) items and services that are provided solely to
satisfy data collection and analysis needs and that are not
used in the direct clinical management of the patient; or
``(iii) a service that is clearly inconsistent with widely
accepted and established standards of care for a particular
diagnosis.
``(3) Use of in-network providers.--If one or more
participating providers is participating in a clinical trial,
nothing in paragraph (1) shall be construed as preventing a
plan or issuer from requiring that a qualified individual
participate in the trial through such a participating
provider if the provider will accept the individual as a
participant in the trial.
``(4) Use of out-of-network.--Notwithstanding paragraph
(3), paragraph (1) shall apply to a qualified individual
participating in an approved clinical trial that is conducted
outside the State in which the qualified individual resides.
``(b) Qualified Individual Defined.--For purposes of
subsection (a), the term `qualified individual' means an
individual who is a participant or beneficiary in a health
plan or with coverage described in subsection (a)(1) and who
meets the following conditions:
``(1) The individual is eligible to participate in an
approved clinical trial according to the trial protocol with
respect to treatment of cancer or other life-threatening
disease or condition.
``(2) Either--
``(A) the referring health care professional is a
participating health care provider and has concluded that the
individual's participation in such trial would be appropriate
based upon the individual meeting the conditions described in
paragraph (1); or
``(B) the participant or beneficiary provides medical and
scientific information establishing that the individual's
participation in such trial would be appropriate based upon
the individual meeting the conditions described in paragraph
(1).
``(c) Limitations on Coverage.--This section shall not be
construed to require a group health plan, or a health
insurance issuer offering group or individual health
insurance coverage, to provide benefits for routine patient
care services provided outside of the plan's (or coverage's)
health care provider network unless out-of-network benefits
are otherwise provided under the plan (or coverage).
``(d) Approved Clinical Trial Defined.--
``(1) In general.--In this section, the term `approved
clinical trial' means a phase I, phase II, phase III, or
phase IV clinical trial that is conducted in relation to the
prevention, detection, or treatment of cancer or other life-
threatening disease or condition and is described in any of
the following subparagraphs:
``(A) Federally funded trials.--The study or investigation
is approved or funded (which may include funding through in-
kind contributions) by one or more of the following:
``(i) The National Institutes of Health.
``(ii) The Centers for Disease Control and Prevention.
``(iii) The Agency for Health Care Research and Quality.
``(iv) The Centers for Medicare & Medicaid Services.
``(v) cooperative group or center of any of the entities
described in clauses (i) through (iv) or the Department of
Defense or the Department of Veterans Affairs.
``(vi) A qualified non-governmental research entity
identified in the guidelines issued by the National
Institutes of Health for center support grants.
``(vii) Any of the following if the conditions described in
paragraph (2) are met:
``(I) The Department of Veterans Affairs.
``(II) The Department of Defense.
``(III) The Department of Energy.
``(B) The study or investigation is conducted under an
investigational new drug application reviewed by the Food and
Drug Administration.
``(C) The study or investigation is a drug trial that is
exempt from having such an investigational new drug
application.
``(2) Conditions for departments.--The conditions described
in this paragraph, for a study or investigation conducted by
a Department, are that the study or investigation has been
reviewed and approved through a system of peer review that
the Secretary determines--
``(A) to be comparable to the system of peer review of
studies and investigations used by the National Institutes of
Health, and
``(B) assures unbiased review of the highest scientific
standards by qualified individuals who have no interest in
the outcome of the review.
``(e) Life-threatening Condition Defined.--In this section,
the term `life-threatening condition' means any disease or
condition from which the likelihood of death is probable
unless the course of the disease or condition is interrupted.
``(f) Construction.--Nothing in this section shall be
construed to limit a plan's or issuer's coverage with respect
to clinical trials.
``(g) Application to FEHBP.--Notwithstanding any provision
of chapter 89 of title 5, United States Code, this section
shall apply to health plans offered under the program under
such chapter.
``(h) Preemption.--Notwithstanding any other provision of
this Act, nothing in this section shall preempt State laws
that require a clinical trials policy for State regulated
health insurance plans that is in addition to the policy
required under this section.''.
(d) Section 1251(a) of this Act is amended--
(1) in paragraph (2), by striking ``With'' and inserting
``Except as provided in paragraph (3), with''; and
(2) by adding at the end the following:
``(3) Application of certain provisions.--The provisions of
sections 2715 and 2718 of the Public Health Service Act (as
added by subtitle A) shall apply to grandfathered health
plans for plan years beginning on or after the date of
enactment of this Act.''.
(e) Section 1253 of this Act is amended insert before the
period the following: ``, except that--
``(1) section 1251 shall take effect on the date of
enactment of this Act; and
``(2) the provisions of section 2704 of the Public Health
Service Act (as amended by section 1201), as they apply to
enrollees who are under 19 years of age, shall become
effective for plan years beginning on or after the date that
is 6 months after the date of enactment of this Act.''.
(f) Subtitle C of title I of this Act is amended--
(1) by redesignating section 1253 as section 1255; and
(2) by inserting after section 1252, the following:
``SEC. 1253. ANNUAL REPORT ON SELF-INSURED PLANS.
``Not later than 1 year after the date of enactment of this
Act, and annually thereafter, the Secretary of Labor shall
prepare an aggregate annual report, using data collected from
the Annual Return/Report of Employee Benefit Plan (Department
of Labor Form 5500), that shall include general information
on self-insured group health plans (including plan type,
number of participants, benefits offered, funding
arrangements, and benefit arrangements) as well as data from
the financial filings of self-insured employers (including
information on assets, liabilities, contributions,
investments, and expenses). The Secretary shall submit such
reports to the appropriate committees of Congress.
``SEC. 1254. STUDY OF LARGE GROUP MARKET.
``(a) In General.--The Secretary of Health and Human
Services shall conduct a study of the fully-insured and self-
insured group health plan markets to--
``(1) compare the characteristics of employers (including
industry, size, and other characteristics as determined
appropriate by the Secretary), health plan benefits,
financial solvency, capital reserve levels, and the risks of
becoming insolvent; and
``(2) determine the extent to which new insurance market
reforms are likely to cause adverse selection in the large
group market or to encourage small and midsize employers to
self-insure.
``(b) Collection of Information.--In conducting the study
under subsection (a), the Secretary, in coordination with the
Secretary of Labor, shall collect information and analyze--
``(1) the extent to which self-insured group health plans
can offer less costly coverage and, if so, whether lower
costs are due to more efficient plan administration and lower
overhead or to the denial of claims and the offering very
limited benefit packages;
``(2) claim denial rates, plan benefit fluctuations (to
evaluate the extent that plans scale back health benefits
during economic downturns), and the impact of the limited
recourse options on consumers; and
``(3) any potential conflict of interest as it relates to
the health care needs of self-insured enrollees and self-
insured employer's financial contribution or profit margin,
and the impact of such conflict on administration of the
health plan.
``(c) Report.--Not later than 1 year after the date of
enactment of this Act, the Secretary
[[Page H2120]]
shall submit to the appropriate committees of Congress a
report concerning the results of the study conducted under
subsection (a).''.
SEC. 10104. AMENDMENTS TO SUBTITLE D.
(a) Section 1301(a) of this Act is amended by striking
paragraph (2) and inserting the following:
``(2) Inclusion of co-op plans and multi-state qualified
health plans.--Any reference in this title to a qualified
health plan shall be deemed to include a qualified health
plan offered through the CO-OP program under section 1322,
and a multi-State plan under section 1334, unless
specifically provided for otherwise.
``(3) Treatment of qualified direct primary care medical
home plans.--The Secretary of Health and Human Services shall
permit a qualified health plan to provide coverage through a
qualified direct primary care medical home plan that meets
criteria established by the Secretary, so long as the
qualified health plan meets all requirements that are
otherwise applicable and the services covered by the medical
home plan are coordinated with the entity offering the
qualified health plan.
``(4) Variation based on rating area.--A qualified health
plan, including a multi-State qualified health plan, may as
appropriate vary premiums by rating area (as defined in
section 2701(a)(2) of the Public Health Service Act).''.
(b) Section 1302 of this Act is amended--
(1) in subsection (d)(2)(B), by striking ``may issue'' and
inserting ``shall issue''; and
(2) by adding at the end the following:
``(g) Payments to Federally-qualified Health Centers.--If
any item or service covered by a qualified health plan is
provided by a Federally-qualified health center (as defined
in section 1905(l)(2)(B) of the Social Security Act (42
U.S.C. 1396d(l)(2)(B)) to an enrollee of the plan, the
offeror of the plan shall pay to the center for the item or
service an amount that is not less than the amount of payment
that would have been paid to the center under section
1902(bb) of such Act (42 U.S.C. 1396a(bb)) for such item or
service.''.
(c) Section 1303 of this Act is amended to read as follows:
``SEC. 1303. SPECIAL RULES.
``(a) State Opt-out of Abortion Coverage.--
``(1) In general.--A State may elect to prohibit abortion
coverage in qualified health plans offered through an
Exchange in such State if such State enacts a law to provide
for such prohibition.
``(2) Termination of opt out.--A State may repeal a law
described in paragraph (1) and provide for the offering of
such services through the Exchange.
``(b) Special Rules Relating to Coverage of Abortion
Services.--
``(1) Voluntary choice of coverage of abortion services.--
``(A) In general.--Notwithstanding any other provision of
this title (or any amendment made by this title)--
``(i) nothing in this title (or any amendment made by this
title), shall be construed to require a qualified health plan
to provide coverage of services described in subparagraph
(B)(i) or (B)(ii) as part of its essential health benefits
for any plan year; and
``(ii) subject to subsection (a), the issuer of a qualified
health plan shall determine whether or not the plan provides
coverage of services described in subparagraph (B)(i) or
(B)(ii) as part of such benefits for the plan year.
``(B) Abortion services.--
``(i) Abortions for which public funding is prohibited.--
The services described in this clause are abortions for which
the expenditure of Federal funds appropriated for the
Department of Health and Human Services is not permitted,
based on the law as in effect as of the date that is 6 months
before the beginning of the plan year involved.
``(ii) Abortions for which public funding is allowed.--The
services described in this clause are abortions for which the
expenditure of Federal funds appropriated for the Department
of Health and Human Services is permitted, based on the law
as in effect as of the date that is 6 months before the
beginning of the plan year involved.
``(2) Prohibition on the use of federal funds.--
``(A) In general.--If a qualified health plan provides
coverage of services described in paragraph (1)(B)(i), the
issuer of the plan shall not use any amount attributable to
any of the following for purposes of paying for such
services:
``(i) The credit under section 36B of the Internal Revenue
Code of 1986 (and the amount (if any) of the advance payment
of the credit under section 1412 of the Patient Protection
and Affordable Care Act).
``(ii) Any cost-sharing reduction under section 1402 of the
Patient Protection and Affordable Care Act (and the amount
(if any) of the advance payment of the reduction under
section 1412 of the Patient Protection and Affordable Care
Act).
``(B) Establishment of allocation accounts.--In the case of
a plan to which subparagraph (A) applies, the issuer of the
plan shall--
``(i) collect from each enrollee in the plan (without
regard to the enrollee's age, sex, or family status) a
separate payment for each of the following:
``(I) an amount equal to the portion of the premium to be
paid directly by the enrollee for coverage under the plan of
services other than services described in paragraph (1)(B)(i)
(after reduction for credits and cost-sharing reductions
described in subparagraph (A)); and
``(II) an amount equal to the actuarial value of the
coverage of services described in paragraph (1)(B)(i), and
``(ii) shall deposit all such separate payments into
separate allocation accounts as provided in subparagraph (C).
In the case of an enrollee whose premium for coverage under
the plan is paid through employee payroll deposit, the
separate payments required under this subparagraph shall each
be paid by a separate deposit.
``(C) Segregation of funds.--
``(i) In general.--The issuer of a plan to which
subparagraph (A) applies shall establish allocation accounts
described in clause (ii) for enrollees receiving amounts
described in subparagraph (A).
``(ii) Allocation accounts.--The issuer of a plan to which
subparagraph (A) applies shall deposit--
``(I) all payments described in subparagraph (B)(i)(I) into
a separate account that consists solely of such payments and
that is used exclusively to pay for services other than
services described in paragraph (1)(B)(i); and
``(II) all payments described in subparagraph (B)(i)(II)
into a separate account that consists solely of such payments
and that is used exclusively to pay for services described in
paragraph (1)(B)(i).
``(D) Actuarial value.--
``(i) In general.--The issuer of a qualified health plan
shall estimate the basic per enrollee, per month cost,
determined on an average actuarial basis, for including
coverage under the qualified health plan of the services
described in paragraph (1)(B)(i).
``(ii) Considerations.--In making such estimate, the
issuer--
``(I) may take into account the impact on overall costs of
the inclusion of such coverage, but may not take into account
any cost reduction estimated to result from such services,
including prenatal care, delivery, or postnatal care;
``(II) shall estimate such costs as if such coverage were
included for the entire population covered; and
``(III) may not estimate such a cost at less than $1 per
enrollee, per month.
``(E) Ensuring compliance with segregation requirements.--
``(i) In general.--Subject to clause (ii), State health
insurance commissioners shall ensure that health plans comply
with the segregation requirements in this subsection through
the segregation of plan funds in accordance with applicable
provisions of generally accepted accounting requirements,
circulars on funds management of the Office of Management and
Budget, and guidance on accounting of the Government
Accountability Office.
``(ii) Clarification.--Nothing in clause (i) shall prohibit
the right of an individual or health plan to appeal such
action in courts of competent jurisdiction.
``(3) Rules relating to notice.--
``(A) Notice.--A qualified health plan that provides for
coverage of the services described in paragraph (1)(B)(i)
shall provide a notice to enrollees, only as part of the
summary of benefits and coverage explanation, at the time of
enrollment, of such coverage.
``(B) Rules relating to payments.--The notice described in
subparagraph (A), any advertising used by the issuer with
respect to the plan, any information provided by the
Exchange, and any other information specified by the
Secretary shall provide information only with respect to the
total amount of the combined payments for services described
in paragraph (1)(B)(i) and other services covered by the
plan.
``(4) No discrimination on basis of provision of
abortion.--No qualified health plan offered through an
Exchange may discriminate against any individual health care
provider or health care facility because of its unwillingness
to provide, pay for, provide coverage of, or refer for
abortions.
``(c) Application of State and Federal Laws Regarding
Abortion.--
``(1) No preemption of state laws regarding abortion.--
Nothing in this Act shall be construed to preempt or
otherwise have any effect on State laws regarding the
prohibition of (or requirement of) coverage, funding, or
procedural requirements on abortions, including parental
notification or consent for the performance of an abortion on
a minor.
``(2) No effect on federal laws regarding abortion.--
``(A) In general.--Nothing in this Act shall be construed
to have any effect on Federal laws regarding--
``(i) conscience protection;
``(ii) willingness or refusal to provide abortion; and
``(iii) discrimination on the basis of the willingness or
refusal to provide, pay for, cover, or refer for abortion or
to provide or participate in training to provide abortion.
``(3) No effect on federal civil rights law.--Nothing in
this subsection shall alter the rights and obligations of
employees and employers under title VII of the Civil Rights
Act of 1964.
``(d) Application of Emergency Services Laws.--Nothing in
this Act shall be construed to relieve any health care
provider from providing emergency services as required by
State or Federal law, including section 1867 of the Social
Security Act (popularly known as `EMTALA').''.
(d) Section 1304 of this Act is amended by adding at the
end the following:
``(e) Educated Health Care Consumers.--The term `educated
health care consumer' means an individual who is
knowledgeable about the health care system, and has
background or experience in making informed decisions
regarding health, medical, and scientific matters.''.
(e) Section 1311(d) of this Act is amended--
(1) in paragraph (3)(B), by striking clause (ii) and
inserting the following:
``(ii) State must assume cost.--A State shall make
payments--
[[Page H2121]]
``(I) to an individual enrolled in a qualified health plan
offered in such State; or
``(II) on behalf of an individual described in subclause
(I) directly to the qualified health plan in which such
individual is enrolled;
to defray the cost of any additional benefits described in
clause (i).''; and
(2) in paragraph (6)(A), by inserting ``educated'' before
``health care''.
(f) Section 1311(e) of this Act is amended--
(1) in paragraph (2), by striking ``may'' in the second
sentence and inserting ``shall''; and
(2) by adding at the end the following:
``(3) Transparency in coverage.--
``(A) In general.--The Exchange shall require health plans
seeking certification as qualified health plans to submit to
the Exchange, the Secretary, the State insurance
commissioner, and make available to the public, accurate and
timely disclosure of the following information:
``(i) Claims payment policies and practices.
``(ii) Periodic financial disclosures.
``(iii) Data on enrollment.
``(iv) Data on disenrollment.
``(v) Data on the number of claims that are denied.
``(vi) Data on rating practices.
``(vii) Information on cost-sharing and payments with
respect to any out-of-network coverage.
``(viii) Information on enrollee and participant rights
under this title.
``(ix) Other information as determined appropriate by the
Secretary.
``(B) Use of plain language.--The information required to
be submitted under subparagraph (A) shall be provided in
plain language. The term `plain language' means language that
the intended audience, including individuals with limited
English proficiency, can readily understand and use because
that language is concise, well-organized, and follows other
best practices of plain language writing. The Secretary and
the Secretary of Labor shall jointly develop and issue
guidance on best practices of plain language writing.
``(C) Cost sharing transparency.--The Exchange shall
require health plans seeking certification as qualified
health plans to permit individuals to learn the amount of
cost-sharing (including deductibles, copayments, and
coinsurance) under the individual's plan or coverage that the
individual would be responsible for paying with respect to
the furnishing of a specific item or service by a
participating provider in a timely manner upon the request of
the individual. At a minimum, such information shall be made
available to such individual through an Internet website and
such other means for individuals without access to the
Internet.
``(D) Group health plans.--The Secretary of Labor shall
update and harmonize the Secretary's rules concerning the
accurate and timely disclosure to participants by group
health plans of plan disclosure, plan terms and conditions,
and periodic financial disclosure with the standards
established by the Secretary under subparagraph (A).''.
(g) Section 1311(g)(1) of this Act is amended--
(1) in subparagraph (C), by striking ``; and'' and
inserting a semicolon;
(2) in subparagraph (D), by striking the period and
inserting ``; and''; and
(3) by adding at the end the following:
``(E) the implementation of activities to reduce health and
health care disparities, including through the use of
language services, community outreach, and cultural
competency trainings.''.
(h) Section 1311(i)(2)((B) of this Act is amended by
striking ``small business development centers'' and inserting
``resource partners of the Small Business Administration''.
(i) Section 1312 of this Act is amended--
(1) in subsection (a)(1), by inserting ``and for which such
individual is eligible'' before the period;
(2) in subsection (e)--
(A) in paragraph (1), by inserting ``and employers'' after
``enroll individuals''; and
(B) by striking the flush sentence at the end; and
(3) in subsection (f)(1)(A)(ii), by striking the
parenthetical.
(j)(1) Subparagraph (B) of section 1313(a)(6) of this Act
is hereby deemed null, void, and of no effect.
(2) Section 3730(e) of title 31, United States Code, is
amended by striking paragraph (4) and inserting the
following:
``(4)(A) The court shall dismiss an action or claim under
this section, unless opposed by the Government, if
substantially the same allegations or transactions as alleged
in the action or claim were publicly disclosed--
``(i) in a Federal criminal, civil, or administrative
hearing in which the Government or its agent is a party;
``(ii) in a congressional, Government Accountability
Office, or other Federal report, hearing, audit, or
investigation; or
``(iii) from the news media,
unless the action is brought by the Attorney General or the
person bringing the action is an original source of the
information.
``(B) For purposes of this paragraph, ``original source''
means an individual who either (i) prior to a public
disclosure under subsection (e)(4)(a), has voluntarily
disclosed to the Government the information on which
allegations or transactions in a claim are based, or (2) who
has knowledge that is independent of and materially adds to
the publicly disclosed allegations or transactions, and who
has voluntarily provided the information to the Government
before filing an action under this section.''.
(k) Section 1313(b) of this Act is amended--
(1) in paragraph (3), by striking ``and'' at the end;
(2) by redesignating paragraph (4) as paragraph (5); and
(3) by inserting after paragraph (3) the following:
``(4) a survey of the cost and affordability of health care
insurance provided under the Exchanges for owners and
employees of small business concerns (as defined under
section 3 of the Small Business Act (15 U.S.C. 632)),
including data on enrollees in Exchanges and individuals
purchasing health insurance coverage outside of Exchanges;
and''.
(l) Section 1322(b) of this Act is amended--
(1) by redesignating paragraph (3) as paragraph (4); and
(2) by inserting after paragraph (2), the following:
``(3) Repayment of loans and grants.--Not later than July
1, 2013, and prior to awarding loans and grants under the CO-
OP program, the Secretary shall promulgate regulations with
respect to the repayment of such loans and grants in a manner
that is consistent with State solvency regulations and other
similar State laws that may apply. In promulgating such
regulations, the Secretary shall provide that such loans
shall be repaid within 5 years and such grants shall be
repaid within 15 years, taking into consideration any
appropriate State reserve requirements, solvency regulations,
and requisite surplus note arrangements that must be
constructed in a State to provide for such repayment prior to
awarding such loans and grants.''.
(m) Part III of subtitle D of title I of this Act is
amended by striking section 1323.
(n) Section 1324(a) of this Act is amended by striking ``,
a community health'' and all that follows through ``1333(b)''
and inserting ``, or a multi-State qualified health plan
under section 1334''.
(o) Section 1331 of this Act is amended--
(1) in subsection (d)(3)(A)(i), by striking ``85'' and
inserting ``95''; and
(2) in subsection (e)(1)(B), by inserting before the
semicolon the following: ``, or, in the case of an alien
lawfully present in the United States, whose income is not
greater than 133 percent of the poverty line for the size of
the family involved but who is not eligible for the Medicaid
program under title XIX of the Social Security Act by reason
of such alien status''.
(p) Section 1333 of this Act is amended by striking
subsection (b).
(q) Part IV of subtitle D of title I of this Act is amended
by adding at the end the following:
``SEC. 1334. MULTI-STATE PLANS.
``(a) Oversight by the Office of Personnel Management.--
``(1) In general.--The Director of the Office of Personnel
Management (referred to in this section as the `Director')
shall enter into contracts with health insurance issuers
(which may include a group of health insurance issuers
affiliated either by common ownership and control or by the
common use of a nationally licensed service mark), without
regard to section 5 of title 41, United States Code, or other
statutes requiring competitive bidding, to offer at least 2
multi-State qualified health plans through each Exchange in
each State. Such plans shall provide individual, or in the
case of small employers, group coverage.
``(2) Terms.--Each contract entered into under paragraph
(1) shall be for a uniform term of at least 1 year, but may
be made automatically renewable from term to term in the
absence of notice of termination by either party. In entering
into such contracts, the Director shall ensure that health
benefits coverage is provided in accordance with the types of
coverage provided for under section 2701(a)(1)(A)(i) of the
Public Health Service Act.
``(3) Non-profit entities.--In entering into contracts
under paragraph (1), the Director shall ensure that at least
one contract is entered into with a non-profit entity.
``(4) Administration.--The Director shall implement this
subsection in a manner similar to the manner in which the
Director implements the contracting provisions with respect
to carriers under the Federal employees health benefit
program under chapter 89 of title 5, United States Code,
including (through negotiating with each multi-state plan)--
``(A) a medical loss ratio;
``(B) a profit margin;
``(C) the premiums to be charged; and
``(D) such other terms and conditions of coverage as are in
the interests of enrollees in such plans.
``(5) Authority to protect consumers.--The Director may
prohibit the offering of any multi-State health plan that
does not meet the terms and conditions defined by the
Director with respect to the elements described in
subparagraphs (A) through (D) of paragraph (4).
``(6) Assured availability of varied coverage.--In entering
into contracts under this subsection, the Director shall
ensure that with respect to multi-State qualified health
plans offered in an Exchange, there is at least one such plan
that does not provide coverage of services described in
section 1303(b)(1)(B)(i).
``(7) Withdrawal.--Approval of a contract under this
subsection may be withdrawn by the Director only after notice
and opportunity for hearing to the issuer concerned without
regard to subchapter II of chapter 5 and chapter 7 of title
5, United States Code.
``(b) Eligibility.--A health insurance issuer shall be
eligible to enter into a contract under subsection (a)(1) if
such issuer--
``(1) agrees to offer a multi-State qualified health plan
that meets the requirements of subsection (c) in each
Exchange in each State;
``(2) is licensed in each State and is subject to all
requirements of State law not inconsistent with this section,
including the standards and requirements that a State imposes
that do not prevent the application of a requirement of part
A of title XXVII of the Public Health Service Act or a
requirement of this title;
[[Page H2122]]
``(3) otherwise complies with the minimum standards
prescribed for carriers offering health benefits plans under
section 8902(e) of title 5, United States Code, to the extent
that such standards do not conflict with a provision of this
title; and
``(4) meets such other requirements as determined
appropriate by the Director, in consultation with the
Secretary.
``(c) Requirements for Multi-State Qualified Health Plan.--
``(1) In general.--A multi-State qualified health plan
meets the requirements of this subsection if, in the
determination of the Director--
``(A) the plan offers a benefits package that is uniform in
each State and consists of the essential benefits described
in section 1302;
``(B) the plan meets all requirements of this title with
respect to a qualified health plan, including requirements
relating to the offering of the bronze, silver, and gold
levels of coverage and catastrophic coverage in each State
Exchange;
``(C) except as provided in paragraph (5), the issuer
provides for determinations of premiums for coverage under
the plan on the basis of the rating requirements of part A of
title XXVII of the Public Health Service Act; and
``(D) the issuer offers the plan in all geographic regions,
and in all States that have adopted adjusted community rating
before the date of enactment of this Act.
``(2) States may offer additional benefits.--Nothing in
paragraph (1)(A) shall preclude a State from requiring that
benefits in addition to the essential health benefits
required under such paragraph be provided to enrollees of a
multi-State qualified health plan offered in such State.
``(3) Credits.--
``(A) In general.--An individual enrolled in a multi-State
qualified health plan under this section shall be eligible
for credits under section 36B of the Internal Revenue Code of
1986 and cost sharing assistance under section 1402 in the
same manner as an individual who is enrolled in a qualified
health plan.
``(B) No additional federal cost.--A requirement by a State
under paragraph (2) that benefits in addition to the
essential health benefits required under paragraph (1)(A) be
provided to enrollees of a multi-State qualified health plan
shall not affect the amount of a premium tax credit provided
under section 36B of the Internal Revenue Code of 1986 with
respect to such plan.
``(4) State must assume cost.--A State shall make
payments--
``(A) to an individual enrolled in a multi-State qualified
health plan offered in such State; or
``(B) on behalf of an individual described in subparagraph
(A) directly to the multi-State qualified health plan in
which such individual is enrolled;
to defray the cost of any additional benefits described in
paragraph (2).
``(5) Application of certain state rating requirements.--
With respect to a multi-State qualified health plan that is
offered in a State with age rating requirements that are
lower than 3:1, the State may require that Exchanges
operating in such State only permit the offering of such
multi-State qualified health plans if such plans comply with
the State's more protective age rating requirements.
``(d) Plans Deemed To Be Certified.--A multi-State
qualified health plan that is offered under a contract under
subsection (a) shall be deemed to be certified by an Exchange
for purposes of section 1311(d)(4)(A).
``(e) Phase-in.--Notwithstanding paragraphs (1) and (2) of
subsection (b), the Director shall enter into a contract with
a health insurance issuer for the offering of a multi-State
qualified health plan under subsection (a) if--
``(1) with respect to the first year for which the issuer
offers such plan, such issuer offers the plan in at least 60
percent of the States;
``(2) with respect to the second such year, such issuer
offers the plan in at least 70 percent of the States;
``(3) with respect to the third such year, such issuer
offers the plan in at least 85 percent of the States; and
``(4) with respect to each subsequent year, such issuer
offers the plan in all States.
``(f) Applicability.--The requirements under chapter 89 of
title 5, United States Code, applicable to health benefits
plans under such chapter shall apply to multi-State qualified
health plans provided for under this section to the extent
that such requirements do not conflict with a provision of
this title.
``(g) Continued Support for FEHBP.--
``(1) Maintenance of effort.--Nothing in this section shall
be construed to permit the Director to allocate fewer
financial or personnel resources to the functions of the
Office of Personnel Management related to the administration
of the Federal Employees Health Benefit Program under chapter
89 of title 5, United States Code.
``(2) Separate risk pool.--Enrollees in multi-State
qualified health plans under this section shall be treated as
a separate risk pool apart from enrollees in the Federal
Employees Health Benefit Program under chapter 89 of title 5,
United States Code.
``(3) Authority to establish separate entities.--The
Director may establish such separate units or offices within
the Office of Personnel Management as the Director determines
to be appropriate to ensure that the administration of multi-
State qualified health plans under this section does not
interfere with the effective administration of the Federal
Employees Health Benefit Program under chapter 89 of title 5,
United States Code.
``(4) Effective oversight.--The Director may appoint such
additional personnel as may be necessary to enable the
Director to carry out activities under this section.
``(5) Assurance of separate program.--In carrying out this
section, the Director shall ensure that the program under
this section is separate from the Federal Employees Health
Benefit Program under chapter 89 of title 5, United States
Code. Premiums paid for coverage under a multi-State
qualified health plan under this section shall not be
considered to be Federal funds for any purposes.
``(6) FEHBP plans not required to participate.--Nothing in
this section shall require that a carrier offering coverage
under the Federal Employees Health Benefit Program under
chapter 89 of title 5, United States Code, also offer a
multi-State qualified health plan under this section.
``(h) Advisory Board.--The Director shall establish an
advisory board to provide recommendations on the activities
described in this section. A significant percentage of the
members of such board shall be comprised of enrollees in a
multi-State qualified health plan, or representatives of such
enrollees.
``(i) Authorization of Appropriations.--There is authorized
to be appropriated, such sums as may be necessary to carry
out this section.''.
(r) Section 1341 of this Act is amended--
(1) in the section heading, by striking ``AND SMALL GROUP
MARKETS'' and inserting ``MARKET'';
(2) in subsection (b)(2)(B), by striking ``paragraph
(1)(A)'' and inserting ``paragraph (1)(B)''; and
(3) in subsection (c)(1)(A), by striking ``and small group
markets'' and inserting ``market''.
SEC. 10105. AMENDMENTS TO SUBTITLE E.
(a) Section 36B(b)(3)(A)(ii) of the Internal Revenue Code
of 1986, as added by section 1401(a) of this Act, is amended
by striking ``is in excess of'' and inserting ``equals or
exceeds''.
(b) Section 36B(c)(1)(A) of the Internal Revenue Code of
1986, as added by section 1401(a) of this Act, is amended by
inserting ``equals or'' before ``exceeds''.
(c) Section 36B(c)(2)(C)(iv) of the Internal Revenue Code
of 1986, as added by section 1401(a) of this Act, is amended
by striking ``subsection (b)(3)(A)(ii)'' and inserting
``subsection (b)(3)(A)(iii)''.
(d) Section 1401(d) of this Act is amended by adding at the
end the following:
``(3) Section 6211(b)(4)(A) of the Internal Revenue Code of
1986 is amended by inserting `36B,' after `36A,'.''.
(e)(1) Subparagraph (B) of section 45R(d)(3) of the
Internal Revenue Code of 1986, as added by section 1421(a) of
this Act, is amended to read as follows:
``(B) Dollar amount.--For purposes of paragraph (1)(B) and
subsection (c)(2)--
``(i) 2010, 2011, 2012, and 2013.--The dollar amount in
effect under this paragraph for taxable years beginning in
2010, 2011, 2012, or 2013 is $25,000.
``(ii) Subsequent years.--In the case of a taxable year
beginning in a calendar year after 2013, the dollar amount in
effect under this paragraph shall be equal to $25,000,
multiplied by the cost-of-living adjustment under section
1(f)(3) for the calendar year, determined by substituting
`calendar year 2012' for `calendar year 1992' in subparagraph
(B) thereof.''.
(2) Subsection (g) of section 45R of the Internal Revenue
Code of 1986, as added by section 1421(a) of this Act, is
amended by striking ``2011'' both places it appears and
inserting ``2010, 2011''.
(3) Section 280C(h) of the Internal Revenue Code of 1986,
as added by section 1421(d)(1) of this Act, is amended by
striking ``2011'' and inserting ``2010, 2011''.
(4) Section 1421(f) of this Act is amended by striking
``2010'' both places it appears and inserting ``2009''.
(5) The amendments made by this subsection shall take
effect as if included in the enactment of section 1421 of
this Act.
(f) Part I of subtitle E of title I of this Act is amended
by adding at the end of subpart B, the following:
``SEC. 1416. STUDY OF GEOGRAPHIC VARIATION IN APPLICATION OF
FPL.
``(a) In General.--The Secretary shall conduct a study to
examine the feasibility and implication of adjusting the
application of the Federal poverty level under this subtitle
(and the amendments made by this subtitle) for different
geographic areas so as to reflect the variations in cost-of-
living among different areas within the United States. If the
Secretary determines that an adjustment is feasible, the
study should include a methodology to make such an
adjustment. Not later than January 1, 2013, the Secretary
shall submit to Congress a report on such study and shall
include such recommendations as the Secretary determines
appropriate.
``(b) Inclusion of Territories.--
``(1) In general.--The Secretary shall ensure that the
study under subsection (a) covers the territories of the
United States and that special attention is paid to the
disparity that exists among poverty levels and the cost of
living in such territories and to the impact of such
disparity on efforts to expand health coverage and ensure
health care.
``(2) Territories defined.--In this subsection, the term
`territories of the United States' includes the Commonwealth
of Puerto Rico, the United States Virgin Islands, Guam, the
Northern Mariana Islands, and any other territory or
possession of the United States.''.
SEC. 10106. AMENDMENTS TO SUBTITLE F.
(a) Section 1501(a)(2) of this Act is amended to read as
follows:
``(2) Effects on the national economy and interstate
commerce.--The effects described in this paragraph are the
following:
``(A) The requirement regulates activity that is commercial
and economic in nature: economic
[[Page H2123]]
and financial decisions about how and when health care is
paid for, and when health insurance is purchased. In the
absence of the requirement, some individuals would make an
economic and financial decision to forego health insurance
coverage and attempt to self-insure, which increases
financial risks to households and medical providers.
``(B) Health insurance and health care services are a
significant part of the national economy. National health
spending is projected to increase from $2,500,000,000,000, or
17.6 percent of the economy, in 2009 to $4,700,000,000,000 in
2019. Private health insurance spending is projected to be
$854,000,000,000 in 2009, and pays for medical supplies,
drugs, and equipment that are shipped in interstate commerce.
Since most health insurance is sold by national or regional
health insurance companies, health insurance is sold in
interstate commerce and claims payments flow through
interstate commerce.
``(C) The requirement, together with the other provisions
of this Act, will add millions of new consumers to the health
insurance market, increasing the supply of, and demand for,
health care services, and will increase the number and share
of Americans who are insured.
``(D) The requirement achieves near-universal coverage by
building upon and strengthening the private employer-based
health insurance system, which covers 176,000,000 Americans
nationwide. In Massachusetts, a similar requirement has
strengthened private employer-based coverage: despite the
economic downturn, the number of workers offered employer-
based coverage has actually increased.
``(E) The economy loses up to $207,000,000,000 a year
because of the poorer health and shorter lifespan of the
uninsured. By significantly reducing the number of the
uninsured, the requirement, together with the other
provisions of this Act, will significantly reduce this
economic cost.
``(F) The cost of providing uncompensated care to the
uninsured was $43,000,000,000 in 2008. To pay for this cost,
health care providers pass on the cost to private insurers,
which pass on the cost to families. This cost-shifting
increases family premiums by on average over $1,000 a year.
By significantly reducing the number of the uninsured, the
requirement, together with the other provisions of this Act,
will lower health insurance premiums.
``(G) 62 percent of all personal bankruptcies are caused in
part by medical expenses. By significantly increasing health
insurance coverage, the requirement, together with the other
provisions of this Act, will improve financial security for
families.
``(H) Under the Employee Retirement Income Security Act of
1974 (29 U.S.C. 1001 et seq.), the Public Health Service Act
(42 U.S.C. 201 et seq.), and this Act, the Federal Government
has a significant role in regulating health insurance. The
requirement is an essential part of this larger regulation of
economic activity, and the absence of the requirement would
undercut Federal regulation of the health insurance market.
``(I) Under sections 2704 and 2705 of the Public Health
Service Act (as added by section 1201 of this Act), if there
were no requirement, many individuals would wait to purchase
health insurance until they needed care. By significantly
increasing health insurance coverage, the requirement,
together with the other provisions of this Act, will minimize
this adverse selection and broaden the health insurance risk
pool to include healthy individuals, which will lower health
insurance premiums. The requirement is essential to creating
effective health insurance markets in which improved health
insurance products that are guaranteed issue and do not
exclude coverage of pre-existing conditions can be sold.
``(J) Administrative costs for private health insurance,
which were $90,000,000,000 in 2006, are 26 to 30 percent of
premiums in the current individual and small group markets.
By significantly increasing health insurance coverage and the
size of purchasing pools, which will increase economies of
scale, the requirement, together with the other provisions of
this Act, will significantly reduce administrative costs and
lower health insurance premiums. The requirement is essential
to creating effective health insurance markets that do not
require underwriting and eliminate its associated
administrative costs.''.
(b)(1) Section 5000A(b)(1) of the Internal Revenue Code of
1986, as added by section 1501(b) of this Act, is amended to
read as follows:
``(1) In general.--If a taxpayer who is an applicable
individual, or an applicable individual for whom the taxpayer
is liable under paragraph (3), fails to meet the requirement
of subsection (a) for 1 or more months, then, except as
provided in subsection (e), there is hereby imposed on the
taxpayer a penalty with respect to such failures in the
amount determined under subsection (c).''.
(2) Paragraphs (1) and (2) of section 5000A(c) of the
Internal Revenue Code of 1986, as so added, are amended to
read as follows:
``(1) In general.--The amount of the penalty imposed by
this section on any taxpayer for any taxable year with
respect to failures described in subsection (b)(1) shall be
equal to the lesser of--
``(A) the sum of the monthly penalty amounts determined
under paragraph (2) for months in the taxable year during
which 1 or more such failures occurred, or
``(B) an amount equal to the national average premium for
qualified health plans which have a bronze level of coverage,
provide coverage for the applicable family size involved, and
are offered through Exchanges for plan years beginning in the
calendar year with or within which the taxable year ends.
``(2) Monthly penalty amounts.--For purposes of paragraph
(1)(A), the monthly penalty amount with respect to any
taxpayer for any month during which any failure described in
subsection (b)(1) occurred is an amount equal to \1/12\ of
the greater of the following amounts:
``(A) Flat dollar amount.--An amount equal to the lesser
of--
``(i) the sum of the applicable dollar amounts for all
individuals with respect to whom such failure occurred during
such month, or
``(ii) 300 percent of the applicable dollar amount
(determined without regard to paragraph (3)(C)) for the
calendar year with or within which the taxable year ends.
``(B) Percentage of income.--An amount equal to the
following percentage of the taxpayer's household income for
the taxable year:
``(i) 0.5 percent for taxable years beginning in 2014.
``(ii) 1.0 percent for taxable years beginning in 2015.
``(iii) 2.0 percent for taxable years beginning after
2015.''.
(3) Section 5000A(c)(3) of the Internal Revenue Code of
1986, as added by section 1501(b) of this Act, is amended by
striking ``$350'' and inserting ``$495''.
(c) Section 5000A(d)(2)(A) of the Internal Revenue Code of
1986, as added by section 1501(b) of this Act, is amended to
read as follows:
``(A) Religious conscience exemption.--Such term shall not
include any individual for any month if such individual has
in effect an exemption under section 1311(d)(4)(H) of the
Patient Protection and Affordable Care Act which certifies
that such individual is--
``(i) a member of a recognized religious sect or division
thereof which is described in section 1402(g)(1), and
``(ii) an adherent of established tenets or teachings of
such sect or division as described in such section.''.
(d) Section 5000A(e)(1)(C) of the Internal Revenue Code of
1986, as added by section 1501(b) of this Act, is amended to
read as follows:
``(C) Special rules for individuals related to employees.--
For purposes of subparagraph (B)(i), if an applicable
individual is eligible for minimum essential coverage through
an employer by reason of a relationship to an employee, the
determination under subparagraph (A) shall be made by
reference to required contribution of the employee.''.
(e) Section 4980H(b) of the Internal Revenue Code of 1986,
as added by section 1513(a) of this Act, is amended to read
as follows:
``(b) Large Employers With Waiting Periods Exceeding 60
Days.--
``(1) In general.--In the case of any applicable large
employer which requires an extended waiting period to enroll
in any minimum essential coverage under an employer-sponsored
plan (as defined in section 5000A(f)(2)), there is hereby
imposed on the employer an assessable payment of $600 for
each full-time employee of the employer to whom the extended
waiting period applies.
``(2) Extended waiting period.--The term `extended waiting
period' means any waiting period (as defined in section
2701(b)(4) of the Public Health Service Act) which exceeds 60
days.''.
(f)(1) Subparagraph (A) of section 4980H(d)(4) of the
Internal Revenue Code of 1986, as added by section 1513(a) of
this Act, is amended by inserting ``, with respect to any
month,'' after ``means''.
(2) Section 4980H(d)(2) of the Internal Revenue Code of
1986, as added by section 1513(a) of this Act, is amended by
adding at the end the following:
``(D) Application to construction industry employers.--In
the case of any employer the substantial annual gross
receipts of which are attributable to the construction
industry--
``(i) subparagraph (A) shall be applied by substituting
`who employed an average of at least 5 full-time employees on
business days during the preceding calendar year and whose
annual payroll expenses exceed $250,000 for such preceding
calendar year' for `who employed an average of at least 50
full-time employees on business days during the preceding
calendar year', and
``(ii) subparagraph (B) shall be applied by substituting
`5' for `50'.''.
(3) The amendment made by paragraph (2) shall apply to
months beginning after December 31, 2013.
(g) Section 6056(b) of the Internal Revenue Code of 1986,
as added by section 1514(a) of the Act, is amended by adding
at the end the following new flush sentence:
``The Secretary shall have the authority to review the
accuracy of the information provided under this subsection,
including the applicable large employer's share under
paragraph (2)(C)(iv).''.
SEC. 10107. AMENDMENTS TO SUBTITLE G.
(a) Section 1562 of this Act is amended, in the amendment
made by subsection (a)(2)(B)(iii), by striking ``subpart 1''
and inserting ``subparts I and II''; and
(b) Subtitle G of title I of this Act is amended--
(1) by redesignating section 1562 (as amended) as section
1563; and
(2) by inserting after section 1561 the following:
``SEC. 1562. GAO STUDY REGARDING THE RATE OF DENIAL OF
COVERAGE AND ENROLLMENT BY HEALTH INSURANCE
ISSUERS AND GROUP HEALTH PLANS.
``(a) In General.--The Comptroller General of the United
States (referred to in this section as the `Comptroller
General') shall conduct a study of the incidence of denials
of coverage for medical services and denials of applications
to enroll in health insurance plans, as described in
subsection (b), by group health plans and health insurance
issuers.
``(b) Data.--
``(1) In general.--In conducting the study described in
subsection (a), the Comptroller General shall consider
samples of data concerning the following:
[[Page H2124]]
``(A)(i) denials of coverage for medical services to a plan
enrollees, by the types of services for which such coverage
was denied; and
``(ii) the reasons such coverage was denied; and
``(B)(i) incidents in which group health plans and health
insurance issuers deny the application of an individual to
enroll in a health insurance plan offered by such group
health plan or issuer; and
``(ii) the reasons such applications are denied.
``(2) Scope of data.--
``(A) Favorably resolved disputes.--The data that the
Comptroller General considers under paragraph (1) shall
include data concerning denials of coverage for medical
services and denials of applications for enrollment in a plan
by a group health plan or health insurance issuer, where such
group health plan or health insurance issuer later approves
such coverage or application.
``(B) All health plans.--The study under this section shall
consider data from varied group health plans and health
insurance plans offered by health insurance issuers,
including qualified health plans and health plans that are
not qualified health plans.
``(c) Report.--Not later than one year after the date of
enactment of this Act, the Comptroller General shall submit
to the Secretaries of Health and Human Services and Labor a
report describing the results of the study conducted under
this section.
``(d) Publication of Report.--The Secretaries of Health and
Human Services and Labor shall make the report described in
subsection (c) available to the public on an Internet
website.
``SEC. 1563. SMALL BUSINESS PROCUREMENT.
``Part 19 of the Federal Acquisition Regulation, section 15
of the Small Business Act (15 U.S.C. 644), and any other
applicable laws or regulations establishing procurement
requirements relating to small business concerns (as defined
in section 3 of the Small Business Act (15 U.S.C. 632)) may
not be waived with respect to any contract awarded under any
program or other authority under this Act or an amendment
made by this Act.''.
SEC. 10108. FREE CHOICE VOUCHERS.
(a) In General.--An offering employer shall provide free
choice vouchers to each qualified employee of such employer.
(b) Offering Employer.--For purposes of this section, the
term ``offering employer'' means any employer who--
(1) offers minimum essential coverage to its employees
consisting of coverage through an eligible employer-sponsored
plan; and
(2) pays any portion of the costs of such plan.
(c) Qualified Employee.--For purposes of this section--
(1) In general.--The term ``qualified employee'' means,
with respect to any plan year of an offering employer, any
employee--
(A) whose required contribution (as determined under
section 5000A(e)(1)(B)) for minimum essential coverage
through an eligible employer-sponsored plan--
(i) exceeds 8 percent of such employee's household income
for the taxable year described in section 1412(b)(1)(B) which
ends with or within in the plan year; and
(ii) does not exceed 9.8 percent of such employee's
household income for such taxable year;
(B) whose household income for such taxable year is not
greater than 400 percent of the poverty line for a family of
the size involved; and
(C) who does not participate in a health plan offered by
the offering employer.
(2) Indexing.--In the case of any calendar year beginning
after 2014, the Secretary shall adjust the 8 percent under
paragraph (1)(A)(i) and 9.8 percent under paragraph
(1)(A)(ii) for the calendar year to reflect the rate of
premium growth between the preceding calendar year and 2013
over the rate of income growth for such period.
(d) Free Choice Voucher.--
(1) Amount.--
(A) In general.--The amount of any free choice voucher
provided under subsection (a) shall be equal to the monthly
portion of the cost of the eligible employer-sponsored plan
which would have been paid by the employer if the employee
were covered under the plan with respect to which the
employer pays the largest portion of the cost of the plan.
Such amount shall be equal to the amount the employer would
pay for an employee with self-only coverage unless such
employee elects family coverage (in which case such amount
shall be the amount the employer would pay for family
coverage).
(B) Determination of cost.--The cost of any health plan
shall be determined under the rules similar to the rules of
section 2204 of the Public Health Service Act, except that
such amount shall be adjusted for age and category of
enrollment in accordance with regulations established by the
Secretary.
(2) Use of vouchers.--An Exchange shall credit the amount
of any free choice voucher provided under subsection (a) to
the monthly premium of any qualified health plan in the
Exchange in which the qualified employee is enrolled and the
offering employer shall pay any amounts so credited to the
Exchange.
(3) Payment of excess amounts.--If the amount of the free
choice voucher exceeds the amount of the premium of the
qualified health plan in which the qualified employee is
enrolled for such month, such excess shall be paid to the
employee.
(e) Other Definitions.--Any term used in this section which
is also used in section 5000A of the Internal Revenue Code of
1986 shall have the meaning given such term under such
section 5000A.
(f) Exclusion From Income for Employee.--
(1) In general.--Part III of subchapter B of chapter 1 of
the Internal Revenue Code of 1986 is amended by inserting
after section 139C the following new section:
``SEC. 139D. FREE CHOICE VOUCHERS.
``Gross income shall not include the amount of any free
choice voucher provided by an employer under section 10108 of
the Patient Protection and Affordable Care Act to the extent
that the amount of such voucher does not exceed the amount
paid for a qualified health plan (as defined in section 1301
of such Act) by the taxpayer.''.
(2) Clerical amendment.--The table of sections for part III
of subchapter B of chapter 1 of such Code is amended by
inserting after the item relating to section 139C the
following new item:
``Sec. 139D. Free choice vouchers.''.
(3) Effective date.--The amendments made by this subsection
shall apply to vouchers provided after December 31, 2013.
(g) Deduction Allowed to Employer.--
(1) In general.--Section 162(a) of the Internal Revenue
Code of 1986 is amended by adding at the end the following
new sentence: ``For purposes of paragraph (1), the amount of
a free choice voucher provided under section 10108 of the
Patient Protection and Affordable Care Act shall be treated
as an amount for compensation for personal services actually
rendered.''.
(2) Effective date.--The amendments made by this subsection
shall apply to vouchers provided after December 31, 2013.
(h) Voucher Taken Into Account in Determining Premium
Credit.--
(1) In general.--Subsection (c)(2) of section 36B of the
Internal Revenue Code of 1986, as added by section 1401, is
amended by adding at the end the following new subparagraph:
``(D) Exception for individual receiving free choice
vouchers.--The term `coverage month' shall not include any
month in which such individual has a free choice voucher
provided under section 10108 of the Patient Protection and
Affordable Care Act.''.
(2) Effective date.--The amendment made by this subsection
shall apply to taxable years beginning after December 31,
2013.
(i) Coordination With Employer Responsibilities.--
(1) Shared responsibility penalty.--
(A) In general.--Subsection (c) of section 4980H of the
Internal Revenue Code of 1986, as added by section 1513, is
amended by adding at the end the following new paragraph:
``(3) Special rules for employers providing free choice
vouchers.--No assessable payment shall be imposed under
paragraph (1) for any month with respect to any employee to
whom the employer provides a free choice voucher under
section 10108 of the Patient Protection and Affordable Care
Act for such month.''.
(B) Effective date.--The amendment made by this paragraph
shall apply to months beginning after December 31, 2013.
(2) Notification requirement.--Section 18B(a)(3) of the
Fair Labor Standards Act of 1938, as added by section 1512,
is amended--
(A) by inserting ``and the employer does not offer a free
choice voucher'' after ``Exchange''; and
(B) by striking ``will lose'' and inserting ``may lose''.
(j) Employer Reporting.--
(1) In general.--Subsection (a) of section 6056 of the
Internal Revenue Code of 1986, as added by section 1514, is
amended by inserting ``and every offering employer'' before
``shall''.
(2) Offering employers.--Subsection (f) of section 6056 of
such Code, as added by section 1514, is amended to read as
follows:
``(f) Definitions.--For purposes of this section--
``(1) Offering employer.--
``(A) In general.--The term `offering employer' means any
offering employer (as defined in section 10108(b) of the
Patient Protection and Affordable Care Act) if the required
contribution (within the meaning of section
5000A(e)(1)(B)(i)) of any employee exceeds 8 percent of the
wages (as defined in section 3121(a)) paid to such employee
by such employer.
``(B) Indexing.--In the case of any calendar year beginning
after 2014, the 8 percent under subparagraph (A) shall be
adjusted for the calendar year to reflect the rate of premium
growth between the preceding calendar year and 2013 over the
rate of income growth for such period.
``(2) Other definitions.--Any term used in this section
which is also used in section 4980H shall have the meaning
given such term by section 4980H.''.
(3) Conforming amendments.--
(A) The heading of section 6056 of such Code, as added by
section 1514, is amended by striking ``LARGE'' and inserting
``CERTAIN''.
(B) Section 6056(b)(2)(C) of such Code is amended--
(i) by inserting ``in the case of an applicable large
employer,'' before ``the length'' in clause (i);
(ii) by striking ``and'' at the end of clause (iii);
(iii) by striking ``applicable large employer'' in clause
(iv) and inserting ``employer'';
(iv) by inserting ``and'' at the end of clause (iv); and
(v) by inserting at the end the following new clause:
``(v) in the case of an offering employer, the option for
which the employer pays the largest portion of the cost of
the plan and the portion of the cost paid by the employer in
each of the enrollment categories under such option,''.
(C) Section 6056(d)(2) of such Code is amended by inserting
``or offering employer'' after ``applicable large employer''.
(D) Section 6056(e) of such Code is amended by inserting
``or offering employer'' after ``applicable large employer''.
(E) Section 6724(d)(1)(B)(xxv) of such Code, as added by
section 1514, is amended by striking ``large'' and inserting
``certain''.
[[Page H2125]]
(F) Section 6724(d)(2)(HH) of such Code, as added by
section 1514, is amended by striking ``large'' and inserting
``certain''.
(G) The table of sections for subpart D of part III of
subchapter A of chapter 1 of such Code, as amended by section
1514, is amended by striking ``Large employers'' in the item
relating to section 6056 and inserting ``Certain employers''.
(4) Effective date.--The amendments made by this subsection
shall apply to periods beginning after December 31, 2013.
SEC. 10109. DEVELOPMENT OF STANDARDS FOR FINANCIAL AND
ADMINISTRATIVE TRANSACTIONS.
(a) Additional Transaction Standards and Operating Rules.--
(1) Development of additional transaction standards and
operating rules.--Section 1173(a) of the Social Security Act
(42 U.S.C. 1320d-2(a)), as amended by section 1104(b)(2), is
amended--
(A) in paragraph (1)(B), by inserting before the period the
following: ``, and subject to the requirements under
paragraph (5)''; and
(B) by adding at the end the following new paragraph:
``(5) Consideration of standardization of activities and
items.--
``(A) In general.--For purposes of carrying out paragraph
(1)(B), the Secretary shall solicit, not later than January
1, 2012, and not less than every 3 years thereafter, input
from entities described in subparagraph (B) on--
``(i) whether there could be greater uniformity in
financial and administrative activities and items, as
determined appropriate by the Secretary; and
``(ii) whether such activities should be considered
financial and administrative transactions (as described in
paragraph (1)(B)) for which the adoption of standards and
operating rules would improve the operation of the health
care system and reduce administrative costs.
``(B) Solicitation of input.--For purposes of subparagraph
(A), the Secretary shall seek input from--
``(i) the National Committee on Vital and Health
Statistics, the Health Information Technology Policy
Committee, and the Health Information Technology Standards
Committee; and
``(ii) standard setting organizations and stakeholders, as
determined appropriate by the Secretary.''.
(b) Activities and Items for Initial Consideration.--For
purposes of section 1173(a)(5) of the Social Security Act, as
added by subsection (a), the Secretary of Health and Human
Services (in this section referred to as the ``Secretary'')
shall, not later than January 1, 2012, seek input on
activities and items relating to the following areas:
(1) Whether the application process, including the use of a
uniform application form, for enrollment of health care
providers by health plans could be made electronic and
standardized.
(2) Whether standards and operating rules described in
section 1173 of the Social Security Act should apply to the
health care transactions of automobile insurance, worker's
compensation, and other programs or persons not described in
section 1172(a) of such Act (42 U.S.C. 1320d-1(a)).
(3) Whether standardized forms could apply to financial
audits required by health plans, Federal and State agencies
(including State auditors, the Office of the Inspector
General of the Department of Health and Human Services, and
the Centers for Medicare & Medicaid Services), and other
relevant entities as determined appropriate by the Secretary.
(4) Whether there could be greater transparency and
consistency of methodologies and processes used to establish
claim edits used by health plans (as described in section
1171(5) of the Social Security Act (42 U.S.C. 1320d(5))).
(5) Whether health plans should be required to publish
their timeliness of payment rules.
(c) ICD Coding Crosswalks.--
(1) ICD-9 to icd-10 crosswalk.--The Secretary shall task
the ICD-9-CM Coordination and Maintenance Committee to
convene a meeting, not later than January 1, 2011, to receive
input from appropriate stakeholders (including health plans,
health care providers, and clinicians) regarding the
crosswalk between the Ninth and Tenth Revisions of the
International Classification of Diseases (ICD-9 and ICD-10,
respectively) that is posted on the website of the Centers
for Medicare & Medicaid Services, and make recommendations
about appropriate revisions to such crosswalk.
(2) Revision of crosswalk.--For purposes of the crosswalk
described in paragraph (1), the Secretary shall make
appropriate revisions and post any such revised crosswalk on
the website of the Centers for Medicare & Medicaid Services.
(3) Use of revised crosswalk.--For purposes of paragraph
(2), any revised crosswalk shall be treated as a code set for
which a standard has been adopted by the Secretary for
purposes of section 1173(c)(1)(B) of the Social Security Act
(42 U.S.C. 1320d-2(c)(1)(B)).
(4) Subsequent crosswalks.--For subsequent revisions of the
International Classification of Diseases that are adopted by
the Secretary as a standard code set under section 1173(c) of
the Social Security Act (42 U.S.C. 1320d-2(c)), the Secretary
shall, after consultation with the appropriate stakeholders,
post on the website of the Centers for Medicare & Medicaid
Services a crosswalk between the previous and subsequent
version of the International Classification of Diseases not
later than the date of implementation of such subsequent
revision.
Subtitle B--Provisions Relating to Title II
PART I--MEDICAID AND CHIP
SEC. 10201. AMENDMENTS TO THE SOCIAL SECURITY ACT AND TITLE
II OF THIS ACT.
(a)(1) Section 1902(a)(10)(A)(i)(IX) of the Social Security
Act (42 U.S.C. 1396a(a)(10)(A)(i)(IX)), as added by section
2004(a), is amended to read as follows:
``(IX) who--
``(aa) are under 26 years of age;
``(bb) are not described in or enrolled under any of
subclauses (I) through (VII) of this clause or are described
in any of such subclauses but have income that exceeds the
level of income applicable under the State plan for
eligibility to enroll for medical assistance under such
subclause;
``(cc) were in foster care under the responsibility of the
State on the date of attaining 18 years of age or such higher
age as the State has elected under section 475(8)(B)(iii);
and
``(dd) were enrolled in the State plan under this title or
under a waiver of the plan while in such foster care;''.
(2) Section 1902(a)(10) of the Social Security Act (42
U.S.C. 1396a(a)(10), as amended by section 2001(a)(5)(A), is
amended in the matter following subparagraph (G), by striking
``and (XV)'' and inserting ``(XV)'', and by inserting ``and
(XVI) if an individual is described in subclause (IX) of
subparagraph (A)(i) and is also described in subclause (VIII)
of that subparagraph, the medical assistance shall be made
available to the individual through subclause (IX) instead of
through subclause (VIII)'' before the semicolon.
(3) Section 2004(d) of this Act is amended by striking
``2019'' and inserting ``2014''.
(b) Section 1902(k)(2) of the Social Security Act (42
U.S.C. 1396a(k)(2)), as added by section 2001(a)(4)(A), is
amended by striking ``January 1, 2011'' and inserting ``April
1, 2010''.
(c) Section 1905 of the Social Security Act (42 U.S.C.
1396d), as amended by sections 2001(a)(3), 2001(a)(5)(C),
2006, and 4107(a)(2), is amended--
(1) in subsection (a), in the matter preceding paragraph
(1), by inserting in clause (xiv), ``or
1902(a)(10)(A)(i)(IX)'' before the comma;
(2) in subsection (b), in the first sentence, by inserting
``, (z),'' before ``and (aa)'';
(3) in subsection (y)--
(A) in paragraph (1)(B)(ii)(II), in the first sentence, by
inserting ``includes inpatient hospital services,'' after
``100 percent of the poverty line, that''; and
(B) in paragraph (2)(A), by striking ``on the date of
enactment of the Patient Protection and Affordable Care Act''
and inserting ``as of December 1, 2009'';
(4) by inserting after subsection (y) the following:
``(z) Equitable Support for Certain States.--
``(1)(A) During the period that begins on January 1, 2014,
and ends on September 30, 2019, notwithstanding subsection
(b), the Federal medical assistance percentage otherwise
determined under subsection (b) with respect to a fiscal year
occurring during that period shall be increased by 2.2
percentage points for any State described in subparagraph (B)
for amounts expended for medical assistance for individuals
who are not newly eligible (as defined in subsection (y)(2))
individuals described in subclause (VIII) of section
1902(a)(10)(A)(i).
``(B) For purposes of subparagraph (A), a State described
in this subparagraph is a State that--
``(i) is an expansion State described in subsection
(y)(1)(B)(ii)(II);
``(ii) the Secretary determines will not receive any
payments under this title on the basis of an increased
Federal medical assistance percentage under subsection (y)
for expenditures for medical assistance for newly eligible
individuals (as so defined); and
``(iii) has not been approved by the Secretary to divert a
portion of the DSH allotment for a State to the costs of
providing medical assistance or other health benefits
coverage under a waiver that is in effect on July 2009.
``(2)(A) During the period that begins on January 1, 2014,
and ends on December 31, 2016, notwithstanding subsection
(b), the Federal medical assistance percentage otherwise
determined under subsection (b) with respect to all or any
portion of a fiscal year occurring during that period shall
be increased by .5 percentage point for a State described in
subparagraph (B) for amounts expended for medical assistance
under the State plan under this title or under a waiver of
that plan during that period.
``(B) For purposes of subparagraph (A), a State described
in this subparagraph is a State that--
``(i) is described in clauses (i) and (ii) of paragraph
(1)(B); and
``(ii) is the State with the highest percentage of its
population insured during 2008, based on the Current
Population Survey.
``(3) Notwithstanding subsection (b) and paragraphs (1) and
(2) of this subsection, the Federal medical assistance
percentage otherwise determined under subsection (b) with
respect to all or any portion of a fiscal year that begins on
or after January 1, 2017, for the State of Nebraska, with
respect to amounts expended for newly eligible individuals
described in subclause (VIII) of section 1902(a)(10)(A)(i),
shall be determined as provided for under subsection
(y)(1)(A) (notwithstanding the period provided for in such
paragraph).
``(4) The increase in the Federal medical assistance
percentage for a State under paragraphs (1), (2), or (3)
shall apply only for purposes of this title and shall not
apply with respect to--
``(A) disproportionate share hospital payments described in
section 1923;
``(B) payments under title IV;
``(C) payments under title XXI; and
``(D) payments under this title that are based on the
enhanced FMAP described in section 2105(b).'';
(5) in subsection (aa), is amended by striking ``without
regard to this subsection and subsection (y)'' and inserting
``without regard to this subsection, subsection (y),
subsection (z),
[[Page H2126]]
and section 10202 of the Patient Protection and Affordable
Care Act'' each place it appears;
(6) by adding after subsection (bb), the following:
``(cc) Requirement for Certain States.--Notwithstanding
subsections (y), (z), and (aa), in the case of a State that
requires political subdivisions within the State to
contribute toward the non-Federal share of expenditures
required under the State plan under section 1902(a)(2), the
State shall not be eligible for an increase in its Federal
medical assistance percentage under such subsections if it
requires that political subdivisions pay a greater percentage
of the non-Federal share of such expenditures, or a greater
percentage of the non-Federal share of payments under section
1923, than the respective percentages that would have been
required by the State under the State plan under this title,
State law, or both, as in effect on December 31, 2009, and
without regard to any such increase. Voluntary contributions
by a political subdivision to the non-Federal share of
expenditures under the State plan under this title or to the
non-Federal share of payments under section 1923, shall not
be considered to be required contributions for purposes of
this subsection. The treatment of voluntary contributions,
and the treatment of contributions required by a State under
the State plan under this title, or State law, as provided by
this subsection, shall also apply to the increases in the
Federal medical assistance percentage under section 5001 of
the American Recovery and Reinvestment Act of 2009.''.
(d) Section 1108(g)(4)(B) of the Social Security Act (42
U.S.C. 1308(g)(4)(B)), as added by section 2005(b), is
amended by striking ``income eligibility level in effect for
that population under title XIX or under a waiver'' and
inserting ``the highest income eligibility level in effect
for parents under the commonwealth's or territory's State
plan under title XIX or under a waiver of the plan''.
(e)(1) Section 1923(f) of the Social Security Act (42
U.S.C. 1396r-4(f)), as amended by section 2551, is amended--
(A) in paragraph (6)--
(i) by striking the paragraph heading and inserting the
following: ``Allotment adjustments''; and
(ii) in subparagraph (B), by adding at the end the
following:
``(iii) Allotment for 2d, 3rd, and 4th quarter of fiscal
year 2012, fiscal year 2013, and succeeding fiscal years.--
Notwithstanding the table set forth in paragraph (2) or
paragraph (7):
``(I) 2d, 3rd, and 4th quarter of fiscal year 2012.--The
DSH allotment for Hawaii for the 2d, 3rd, and 4th quarters of
fiscal year 2012 shall be $7,500,000.
``(II) Treatment as a low-dsh state for fiscal year 2013
and succeeding fiscal years.--With respect to fiscal year
2013, and each fiscal year thereafter, the DSH allotment for
Hawaii shall be increased in the same manner as allotments
for low DSH States are increased for such fiscal year under
clause (iii) of paragraph (5)(B).
``(III) Certain hospital payments.--The Secretary may not
impose a limitation on the total amount of payments made to
hospitals under the QUEST section 1115 Demonstration Project
except to the extent that such limitation is necessary to
ensure that a hospital does not receive payments in excess of
the amounts described in subsection (g), or as necessary to
ensure that such payments under the waiver and such payments
pursuant to the allotment provided in this clause do not, in
the aggregate in any year, exceed the amount that the
Secretary determines is equal to the Federal medical
assistance percentage component attributable to
disproportionate share hospital payment adjustments for such
year that is reflected in the budget neutrality provision of
the QUEST Demonstration Project.''; and
(B) in paragraph (7)--
(i) in subparagraph (A), in the matter preceding clause
(i), by striking ``subparagraph (E)'' and inserting
``subparagraphs (E) and (G)'';
(ii) in subparagraph (B)--
(I) in clause (i), by striking subclauses (I) and (II), and
inserting the following:
``(I) if the State is a low DSH State described in
paragraph (5)(B) and has spent not more than 99.90 percent of
the DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to 25 percent;
``(II) if the State is a low DSH State described in
paragraph (5)(B) and has spent more than 99.90 percent of the
DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to 17.5 percent;
``(III) if the State is not a low DSH State described in
paragraph (5)(B) and has spent not more than 99.90 percent of
the DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to 50 percent; and
``(IV) if the State is not a low DSH State described in
paragraph (5)(B) and has spent more than 99.90 percent of the
DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to 35 percent.'';
(II) in clause (ii), by striking subclauses (I) and (II),
and inserting the following:
``(I) if the State is a low DSH State described in
paragraph (5)(B) and has spent not more than 99.90 percent of
the DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to the product of the
percentage reduction in uncovered individuals for the fiscal
year from the preceding fiscal year and 27.5 percent;
``(II) if the State is a low DSH State described in
paragraph (5)(B) and has spent more than 99.90 percent of the
DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to the product of the
percentage reduction in uncovered individuals for the fiscal
year from the preceding fiscal year and 20 percent;
``(III) if the State is not a low DSH State described in
paragraph (5)(B) and has spent not more than 99.90 percent of
the DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to the product of the
percentage reduction in uncovered individuals for the fiscal
year from the preceding fiscal year and 55 percent; and
``(IV) if the State is not a low DSH State described in
paragraph (5)(B) and has spent more than 99.90 percent of the
DSH allotments for the State on average for the period of
fiscal years 2004 through 2008, as of September 30, 2009, the
applicable percentage is equal to the product of the
percentage reduction in uncovered individuals for the fiscal
year from the preceding fiscal year and 40 percent.'';
(III) in subparagraph (E), by striking ``35 percent'' and
inserting ``50 percent''; and
(IV) by adding at the end the following:
``(G) Nonapplication.--The preceding provisions of this
paragraph shall not apply to the DSH allotment determined for
the State of Hawaii for a fiscal year under paragraph (6).''.
(f) Section 2551 of this Act is amended by striking
subsection (b).
(g) Section 2105(d)(3)(B) of the Social Security Act (42
U.S.C. 1397ee(d)(3)(B)), as added by section 2101(b)(1), is
amended by adding at the end the following: ``For purposes of
eligibility for premium assistance for the purchase of a
qualified health plan under section 36B of the Internal
Revenue Code of 1986 and reduced cost-sharing under section
1402 of the Patient Protection and Affordable Care Act,
children described in the preceding sentence shall be deemed
to be ineligible for coverage under the State child health
plan.''.
(h) Clause (i) of subparagraph (C) of section 513(b)(2) of
the Social Security Act, as added by section 2953 of this
Act, is amended to read as follows:
``(i) Healthy relationships, including marriage and family
interactions.''.
(i) Section 1115 of the Social Security Act (42 U.S.C.
1315) is amended by inserting after subsection (c) the
following:
``(d)(1) An application or renewal of any experimental,
pilot, or demonstration project undertaken under subsection
(a) to promote the objectives of title XIX or XXI in a State
that would result in an impact on eligibility, enrollment,
benefits, cost-sharing, or financing with respect to a State
program under title XIX or XXI (in this subsection referred
to as a `demonstration project') shall be considered by the
Secretary in accordance with the regulations required to be
promulgated under paragraph (2).
``(2) Not later than 180 days after the date of enactment
of this subsection, the Secretary shall promulgate
regulations relating to applications for, and renewals of, a
demonstration project that provide for--
``(A) a process for public notice and comment at the State
level, including public hearings, sufficient to ensure a
meaningful level of public input;
``(B) requirements relating to--
``(i) the goals of the program to be implemented or renewed
under the demonstration project;
``(ii) the expected State and Federal costs and coverage
projections of the demonstration project; and
``(iii) the specific plans of the State to ensure that the
demonstration project will be in compliance with title XIX or
XXI;
``(C) a process for providing public notice and comment
after the application is received by the Secretary, that is
sufficient to ensure a meaningful level of public input;
``(D) a process for the submission to the Secretary of
periodic reports by the State concerning the implementation
of the demonstration project; and
``(E) a process for the periodic evaluation by the
Secretary of the demonstration project.
``(3) The Secretary shall annually report to Congress
concerning actions taken by the Secretary with respect to
applications for demonstration projects under this
section.''.
(j) Subtitle F of title III of this Act is amended by
adding at the end the following:
``SEC. 3512. GAO STUDY AND REPORT ON CAUSES OF ACTION.
``(a) Study.--
``(1) In general.--The Comptroller General of the United
States shall conduct a study of whether the development,
recognition, or implementation of any guideline or other
standards under a provision described in paragraph (2) would
result in the establishment of a new cause of action or
claim.
``(2) Provisions described.--The provisions described in
this paragraph include the following:
``(A) Section 2701 (adult health quality measures).
``(B) Section 2702 (payment adjustments for health care
acquired conditions).
``(C) Section 3001 (Hospital Value-Based Purchase Program).
``(D) Section 3002 (improvements to the Physician Quality
Reporting Initiative).
``(E) Section 3003 (improvements to the Physician Feedback
Program).
``(F) Section 3007 (value based payment modifier under
physician fee schedule).
``(G) Section 3008 (payment adjustment for conditions
acquired in hospitals).
``(H) Section 3013 (quality measure development).
[[Page H2127]]
``(I) Section 3014 (quality measurement).
``(J) Section 3021 (Establishment of Center for Medicare
and Medicaid Innovation).
``(K) Section 3025 (hospital readmission reduction
program).
``(L) Section 3501 (health care delivery system research,
quality improvement).
``(M) Section 4003 (Task Force on Clinical and Preventive
Services).
``(N) Section 4301 (research to optimize deliver of public
health services).
``(b) Report.--Not later than 2 years after the date of
enactment of this Act, the Comptroller General of the United
States shall submit to the appropriate committees of
Congress, a report containing the findings made by the
Comptroller General under the study under subsection (a).''.
SEC. 10202. INCENTIVES FOR STATES TO OFFER HOME AND
COMMUNITY-BASED SERVICES AS A LONG-TERM CARE
ALTERNATIVE TO NURSING HOMES.
(a) State Balancing Incentive Payments Program.--
Notwithstanding section 1905(b) of the Social Security Act
(42 U.S.C. 1396d(b)), in the case of a balancing incentive
payment State, as defined in subsection (b), that meets the
conditions described in subsection (c), during the balancing
incentive period, the Federal medical assistance percentage
determined for the State under section 1905(b) of such Act
and, if applicable, increased under subsection (z) or (aa)
shall be increased by the applicable percentage points
determined under subsection (d) with respect to eligible
medical assistance expenditures described in subsection (e).
(b) Balancing Incentive Payment State.--A balancing
incentive payment State is a State--
(1) in which less than 50 percent of the total expenditures
for medical assistance under the State Medicaid program for a
fiscal year for long-term services and supports (as defined
by the Secretary under subsection (f))(1)) are for non-
institutionally-based long-term services and supports
described in subsection (f)(1)(B);
(2) that submits an application and meets the conditions
described in subsection (c); and
(3) that is selected by the Secretary to participate in the
State balancing incentive payment program established under
this section.
(c) Conditions.--The conditions described in this
subsection are the following:
(1) Application.--The State submits an application to the
Secretary that includes, in addition to such other
information as the Secretary shall require--
(A) a proposed budget that details the State's plan to
expand and diversify medical assistance for non-
institutionally-based long-term services and supports
described in subsection (f)(1)(B) under the State Medicaid
program during the balancing incentive period and achieve the
target spending percentage applicable to the State under
paragraph (2), including through structural changes to how
the State furnishes such assistance, such as through the
establishment of a ``no wrong door--single entry point
system'', optional presumptive eligibility, case management
services, and the use of core standardized assessment
instruments, and that includes a description of the new or
expanded offerings of such services that the State will
provide and the projected costs of such services; and
(B) in the case of a State that proposes to expand the
provision of home and community-based services under its
State Medicaid program through a State plan amendment under
section 1915(i) of the Social Security Act, at the option of
the State, an election to increase the income eligibility for
such services from 150 percent of the poverty line to such
higher percentage as the State may establish for such
purpose, not to exceed 300 percent of the supplemental
security income benefit rate established by section
1611(b)(1) of the Social Security Act (42 U.S.C. 1382(b)(1)).
(2) Target spending percentages.--
(A) In the case of a balancing incentive payment State in
which less than 25 percent of the total expenditures for
long-term services and supports under the State Medicaid
program for fiscal year 2009 are for home and community-based
services, the target spending percentage for the State to
achieve by not later than October 1, 2015, is that 25 percent
of the total expenditures for long-term services and supports
under the State Medicaid program are for home and community-
based services.
(B) In the case of any other balancing incentive payment
State, the target spending percentage for the State to
achieve by not later than October 1, 2015, is that 50 percent
of the total expenditures for long-term services and supports
under the State Medicaid program are for home and community-
based services.
(3) Maintenance of eligibility requirements.--The State
does not apply eligibility standards, methodologies, or
procedures for determining eligibility for medical assistance
for non-institutionally-based long-term services and supports
described in subsection (f)(1)(B) under the State Medicaid
program that are more restrictive than the eligibility
standards, methodologies, or procedures in effect for such
purposes on December 31, 2010.
(4) Use of additional funds.--The State agrees to use the
additional Federal funds paid to the State as a result of
this section only for purposes of providing new or expanded
offerings of non-institutionally-based long-term services and
supports described in subsection (f)(1)(B) under the State
Medicaid program.
(5) Structural changes.--The State agrees to make, not
later than the end of the 6-month period that begins on the
date the State submits an application under this section, the
following changes:
(A) ``No wrong door--single entry point system''.--
Development of a statewide system to enable consumers to
access all long-term services and supports through an agency,
organization, coordinated network, or portal, in accordance
with such standards as the State shall establish and that
shall provide information regarding the availability of such
services, how to apply for such services, referral services
for services and supports otherwise available in the
community, and determinations of financial and functional
eligibility for such services and supports, or assistance
with assessment processes for financial and functional
eligibility.
(B) Conflict-free case management services.--Conflict-free
case management services to develop a service plan, arrange
for services and supports, support the beneficiary (and, if
appropriate, the beneficiary's caregivers) in directing the
provision of services and supports for the beneficiary, and
conduct ongoing monitoring to assure that services and
supports are delivered to meet the beneficiary's needs and
achieve intended outcomes.
(C) Core standardized assessment instruments.--Development
of core standardized assessment instruments for determining
eligibility for non-institutionally-based long-term services
and supports described in subsection (f)(1)(B), which shall
be used in a uniform manner throughout the State, to
determine a beneficiary's needs for training, support
services, medical care, transportation, and other services,
and develop an individual service plan to address such needs.
(6) Data collection.--The State agrees to collect from
providers of services and through such other means as the
State determines appropriate the following data:
(A) Services data.--Services data from providers of non-
institutionally-based long-term services and supports
described in subsection (f)(1)(B) on a per-beneficiary basis
and in accordance with such standardized coding procedures as
the State shall establish in consultation with the Secretary.
(B) Quality data.--Quality data on a selected set of core
quality measures agreed upon by the Secretary and the State
that are linked to population-specific outcomes measures and
accessible to providers.
(C) Outcomes measures.--Outcomes measures data on a
selected set of core population-specific outcomes measures
agreed upon by the Secretary and the State that are
accessible to providers and include--
(i) measures of beneficiary and family caregiver experience
with providers;
(ii) measures of beneficiary and family caregiver
satisfaction with services; and
(iii) measures for achieving desired outcomes appropriate
to a specific beneficiary, including employment,
participation in community life, health stability, and
prevention of loss in function.
(d) Applicable Percentage Points Increase in FMAP.--The
applicable percentage points increase is--
(1) in the case of a balancing incentive payment State
subject to the target spending percentage described in
subsection (c)(2)(A), 5 percentage points; and
(2) in the case of any other balancing incentive payment
State, 2 percentage points.
(e) Eligible Medical Assistance Expenditures.--
(1) In general.--Subject to paragraph (2), medical
assistance described in this subsection is medical assistance
for non-institutionally-based long-term services and supports
described in subsection (f)(1)(B) that is provided by a
balancing incentive payment State under its State Medicaid
program during the balancing incentive payment period.
(2) Limitation on payments.--In no case may the aggregate
amount of payments made by the Secretary to balancing
incentive payment States under this section during the
balancing incentive period exceed $3,000,000,000.
(f) Definitions.--In this section:
(1) Long-term services and supports defined.--The term
``long-term services and supports'' has the meaning given
that term by Secretary and may include any of the following
(as defined for purposes of State Medicaid programs):
(A) Institutionally-based long-term services and
supports.--Services provided in an institution, including the
following:
(i) Nursing facility services.
(ii) Services in an intermediate care facility for the
mentally retarded described in subsection (a)(15) of section
1905 of such Act.
(B) Non-institutionally-based long-term services and
supports.--Services not provided in an institution, including
the following:
(i) Home and community-based services provided under
subsection (c), (d), or (i) of section 1915 of such Act or
under a waiver under section 1115 of such Act.
(ii) Home health care services.
(iii) Personal care services.
(iv) Services described in subsection (a)(26) of section
1905 of such Act (relating to PACE program services).
(v) Self-directed personal assistance services described in
section 1915(j) of such Act.
(2) Balancing incentive period.--The term ``balancing
incentive period'' means the period that begins on October 1,
2011, and ends on September 30, 2015.
(3) Poverty line.--The term ``poverty line'' has the
meaning given that term in section 2110(c)(5) of the Social
Security Act (42 U.S.C. 1397jj(c)(5)).
(4) State medicaid program.--The term ``State Medicaid
program'' means the State program for medical assistance
provided under a State plan under title XIX of the Social
Security Act and under any waiver approved with respect to
such State plan.
SEC. 10203. EXTENSION OF FUNDING FOR CHIP THROUGH FISCAL YEAR
2015 AND OTHER CHIP-RELATED PROVISIONS.
(a) Section 1311(c)(1) of this Act is amended by striking
``and'' at the end of subparagraph (G), by striking the
period at the end of subparagraph (H) and inserting ``;
and'', and by adding at the end the following:
[[Page H2128]]
``(I) report to the Secretary at least annually and in such
manner as the Secretary shall require, pediatric quality
reporting measures consistent with the pediatric quality
reporting measures established under section 1139A of the
Social Security Act.''.
(b) Effective as if included in the enactment of the
Children's Health Insurance Program Reauthorization Act of
2009 (Public Law 111-3):
(1) Section 1906(e)(2) of the Social Security Act (42
U.S.C. 1396e(e)(2)) is amended by striking ``means'' and all
that follows through the period and inserting ``has the
meaning given that term in section 2105(c)(3)(A).''.
(2)(A) Section 1906A(a) of the Social Security Act (42
U.S.C. 1396e-1(a)), is amended by inserting before the period
the following: ``and the offering of such a subsidy is cost-
effective, as defined for purposes of section
2105(c)(3)(A)''.
(B) This Act shall be applied without regard to
subparagraph (A) of section 2003(a)(1) of this Act and that
subparagraph and the amendment made by that subparagraph are
hereby deemed null, void, and of no effect.
(3) Section 2105(c)(10) of the Social Security Act (42
U.S.C. 1397ee(c)(10)) is amended--
(A) in subparagraph (A), in the first sentence, by
inserting before the period the following: ``if the offering
of such a subsidy is cost-effective, as defined for purposes
of paragraph (3)(A)'';
(B) by striking subparagraph (M); and
(C) by redesignating subparagraph (N) as subparagraph (M).
(4) Section 2105(c)(3)(A) of the Social Security Act (42
U.S.C. 1397ee(c)(3)(A)) is amended--
(A) in the matter preceding clause (i), by striking ``to''
and inserting ``to--''; and
(B) in clause (ii), by striking the period and inserting a
semicolon.
(c) Section 2105 of the Social Security Act (42 U.S.C.
1397ee), as amended by section 2101, is amended--
(1) in subsection (b), in the second sentence, by striking
``2013'' and inserting ``2015''; and
(2) in subsection (d)(3)--
(A) in subparagraph (A)--
(i) in the first sentence, by inserting ``as a condition of
receiving payments under section 1903(a),'' after ``2019,'';
(ii) in clause (i), by striking ``or'' at the end;
(iii) by redesignating clause (ii) as clause (iii); and
(iv) by inserting after clause (i), the following:
``(ii) after September 30, 2015, enrolling children
eligible to be targeted low-income children under the State
child health plan in a qualified health plan that has been
certified by the Secretary under subparagraph (C); or'';
(B) in subparagraph (B), by striking ``provided coverage''
and inserting ``screened for eligibility for medical
assistance under the State plan under title XIX or a waiver
of that plan and, if found eligible, enrolled in such plan or
a waiver. In the case of such children who, as a result of
such screening, are determined to not be eligible for medical
assistance under the State plan or a waiver under title XIX,
the State shall establish procedures to ensure that the
children are enrolled in a qualified health plan that has
been certified by the Secretary under subparagraph (C) and is
offered''; and
(C) by adding at the end the following:
``(C) Certification of comparability of pediatric coverage
offered by qualified health plans.--With respect to each
State, the Secretary, not later than April 1, 2015, shall
review the benefits offered for children and the cost-sharing
imposed with respect to such benefits by qualified health
plans offered through an Exchange established by the State
under section 1311 of the Patient Protection and Affordable
Care Act and shall certify those plans that offer benefits
for children and impose cost-sharing with respect to such
benefits that the Secretary determines are at least
comparable to the benefits offered and cost-sharing
protections provided under the State child health plan.''.
(d)(1) Section 2104(a) of such Act (42 U.S.C. 1397dd(a)) is
amended--
(A) in paragraph (15), by striking ``and'' at the end; and
(B) by striking paragraph (16) and inserting the following:
``(16) for fiscal year 2013, $17,406,000,000;
``(17) for fiscal year 2014, $19,147,000,000; and
``(18) for fiscal year 2015, for purposes of making 2 semi-
annual allotments--
``(A) $2,850,000,000 for the period beginning on October 1,
2014, and ending on March 31, 2015, and
``(B) $2,850,000,000 for the period beginning on April 1,
2015, and ending on September 30, 2015.''.
(2)(A) Section 2104(m) of such Act (42 U.S.C. 1397dd(m)),
as amended by section 2102(a)(1), is amended--
(i) in the subsection heading, by striking ``2013'' and
inserting ``2015'';
(ii) in paragraph (2)--
(I) in the paragraph heading, by striking ``2012'' and
inserting ``2014''; and
(II) by adding at the end the following:
``(B) Fiscal years 2013 and 2014.--Subject to paragraphs
(4) and (6), from the amount made available under paragraphs
(16) and (17) of subsection (a) for fiscal years 2013 and
2014, respectively, the Secretary shall compute a State
allotment for each State (including the District of Columbia
and each commonwealth and territory) for each such fiscal
year as follows:
``(i) Rebasing in fiscal year 2013.--For fiscal year 2013,
the allotment of the State is equal to the Federal payments
to the State that are attributable to (and countable towards)
the total amount of allotments available under this section
to the State in fiscal year 2012 (including payments made to
the State under subsection (n) for fiscal year 2012 as well
as amounts redistributed to the State in fiscal year 2012),
multiplied by the allotment increase factor under paragraph
(5) for fiscal year 2013.
``(ii) Growth factor update for fiscal year 2014.--For
fiscal year 2014, the allotment of the State is equal to the
sum of--
``(I) the amount of the State allotment under clause (i)
for fiscal year 2013; and
``(II) the amount of any payments made to the State under
subsection (n) for fiscal year 2013,
multiplied by the allotment increase factor under paragraph
(5) for fiscal year 2014.'';
(iii) in paragraph (3)--
(I) in the paragraph heading, by striking ``2013'' and
inserting ``2015'';
(II) in subparagraphs (A) and (B), by striking ``paragraph
(16)'' each place it appears and inserting ``paragraph
(18)'';
(III) in subparagraph (C)--
(aa) by striking ``2012'' each place it appears and
inserting ``2014''; and
(bb) by striking ``2013'' and inserting ``2015''; and
(IV) in subparagraph (D)--
(aa) in clause (i)(I), by striking ``subsection
(a)(16)(A)'' and inserting ``subsection (a)(18)(A)''; and
(bb) in clause (ii)(II), by striking ``subsection
(a)(16)(B)'' and inserting ``subsection (a)(18)(B)'';
(iv) in paragraph (4), by striking ``2013'' and inserting
``2015'';
(v) in paragraph (6)--
(I) in subparagraph (A), by striking ``2013'' and inserting
``2015''; and
(II) in the flush language after and below subparagraph
(B)(ii), by striking ``or fiscal year 2012'' and inserting
``, fiscal year 2012, or fiscal year 2014''; and
(vi) in paragraph (8)--
(I) in the paragraph heading, by striking ``2013'' and
inserting ``2015''; and
(II) by striking ``2013'' and inserting ``2015''.
(B) Section 2104(n) of such Act (42 U.S.C. 1397dd(n)) is
amended--
(i) in paragraph (2)--
(I) in subparagraph (A)(ii)--
(aa) by striking ``2012'' and inserting ``2014''; and
(bb) by striking ``2013'' and inserting ``2015'';
(II) in subparagraph (B)--
(aa) by striking ``2012'' and inserting ``2014''; and
(bb) by striking ``2013'' and inserting ``2015''; and
(ii) in paragraph (3)(A), by striking ``or a semi-annual
allotment period for fiscal year 2013'' and inserting
``fiscal year 2013, fiscal year 2014, or a semi-annual
allotment period for fiscal year 2015''.
(C) Section 2105(g)(4) of such Act (42 U.S.C. 1397ee(g)(4))
is amended--
(i) in the paragraph heading, by striking ``2013'' and
inserting ``2015''; and
(ii) in subparagraph (A), by striking ``2013'' and
inserting ``2015''.
(D) Section 2110(b) of such Act (42 U.S.C. 1397jj(b)) is
amended--
(i) in paragraph (2)(B), by inserting ``except as provided
in paragraph (6),'' before ``a child''; and
(ii) by adding at the end the following new paragraph:
``(6) Exceptions to exclusion of children of employees of a
public agency in the state.--
``(A) In general.--A child shall not be considered to be
described in paragraph (2)(B) if--
``(i) the public agency that employs a member of the
child's family to which such paragraph applies satisfies
subparagraph (B); or
``(ii) subparagraph (C) applies to such child.
``(B) Maintenance of effort with respect to per person
agency contribution for family coverage.--For purposes of
subparagraph (A)(i), a public agency satisfies this
subparagraph if the amount of annual agency expenditures made
on behalf of each employee enrolled in health coverage paid
for by the agency that includes dependent coverage for the
most recent State fiscal year is not less than the amount of
such expenditures made by the agency for the 1997 State
fiscal year, increased by the percentage increase in the
medical care expenditure category of the Consumer Price Index
for All-Urban Consumers (all items: U.S. City Average) for
such preceding fiscal year.
``(C) Hardship exception.--For purposes of subparagraph
(A)(ii), this subparagraph applies to a child if the State
determines, on a case-by-case basis, that the annual
aggregate amount of premiums and cost-sharing imposed for
coverage of the family of the child would exceed 5 percent of
such family's income for the year involved.''.
(E) Section 2113 of such Act (42 U.S.C. 1397mm) is
amended--
(i) in subsection (a)(1), by striking ``2013'' and
inserting ``2015''; and
(ii) in subsection (g), by striking ``$100,000,000 for the
period of fiscal years 2009 through 2013'' and inserting
``$140,000,000 for the period of fiscal years 2009 through
2015''.
(F) Section 108 of Public Law 111-3 is amended by striking
``$11,706,000,000'' and all that follows through the second
sentence and inserting ``$15,361,000,000 to accompany the
allotment made for the period beginning on October 1, 2014,
and ending on March 31, 2015, under section 2104(a)(18)(A) of
the Social Security Act (42 U.S.C. 1397dd(a)(18)(A)), to
remain available until expended. Such amount shall be used to
provide allotments to States under paragraph (3) of section
2104(m) of the Social Security Act (42 U.S.C. 1397dd(m)) for
the first 6 months of fiscal year 2015 in the same manner as
allotments are provided under subsection (a)(18)(A) of such
section 2104 and subject to the same terms and conditions as
apply to the allotments provided from such subsection
(a)(18)(A).''.
PART II--SUPPORT FOR PREGNANT AND PARENTING TEENS AND WOMEN
SEC. 10211. DEFINITIONS.
In this part:
(1) Accompaniment.--The term ``accompaniment'' means
assisting, representing, and accompanying a woman in seeking
judicial relief
[[Page H2129]]
for child support, child custody, restraining orders, and
restitution for harm to persons and property, and in filing
criminal charges, and may include the payment of court costs
and reasonable attorney and witness fees associated
therewith.
(2) Eligible institution of higher education.--The term
``eligible institution of higher education'' means an
institution of higher education (as such term is defined in
section 101 of the Higher Education Act of 1965 (20 U.S.C.
1001)) that has established and operates, or agrees to
establish and operate upon the receipt of a grant under this
part, a pregnant and parenting student services office.
(3) Community service center.--The term ``community service
center'' means a non-profit organization that provides social
services to residents of a specific geographical area via
direct service or by contract with a local governmental
agency.
(4) High school.--The term ``high school'' means any public
or private school that operates grades 10 through 12,
inclusive, grades 9 through 12, inclusive or grades 7 through
12, inclusive.
(5) Intervention services.--The term ``intervention
services'' means, with respect to domestic violence, sexual
violence, sexual assault, or stalking, 24-hour telephone
hotline services for police protection and referral to
shelters.
(6) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(7) State.--The term ``State'' includes the District of
Columbia, any commonwealth, possession, or other territory of
the United States, and any Indian tribe or reservation.
(8) Supportive social services.--The term ``supportive
social services'' means transitional and permanent housing,
vocational counseling, and individual and group counseling
aimed at preventing domestic violence, sexual violence,
sexual assault, or stalking.
(9) Violence.--The term ``violence'' means actual violence
and the risk or threat of violence.
SEC. 10212. ESTABLISHMENT OF PREGNANCY ASSISTANCE FUND.
(a) In General.--The Secretary, in collaboration and
coordination with the Secretary of Education (as
appropriate), shall establish a Pregnancy Assistance Fund to
be administered by the Secretary, for the purpose of awarding
competitive grants to States to assist pregnant and parenting
teens and women.
(b) Use of Fund.--A State may apply for a grant under
subsection (a) to carry out any activities provided for in
section 10213.
(c) Applications.--To be eligible to receive a grant under
subsection (a), a State shall submit to the Secretary an
application at such time, in such manner, and containing such
information as the Secretary may require, including a
description of the purposes for which the grant is being
requested and the designation of a State agency for receipt
and administration of funding received under this part.
SEC. 10213. PERMISSIBLE USES OF FUND.
(a) In General.--A State shall use amounts received under a
grant under section 10212 for the purposes described in this
section to assist pregnant and parenting teens and women.
(b) Institutions of Higher Education.--
(1) In general.--A State may use amounts received under a
grant under section 10212 to make funding available to
eligible institutions of higher education to enable the
eligible institutions to establish, maintain, or operate
pregnant and parenting student services. Such funding shall
be used to supplement, not supplant, existing funding for
such services.
(2) Application.--An eligible institution of higher
education that desires to receive funding under this
subsection shall submit an application to the designated
State agency at such time, in such manner, and containing
such information as the State agency may require.
(3) Matching requirement.--An eligible institution of
higher education that receives funding under this subsection
shall contribute to the conduct of the pregnant and parenting
student services office supported by the funding an amount
from non-Federal funds equal to 25 percent of the amount of
the funding provided. The non-Federal share may be in cash or
in-kind, fairly evaluated, including services, facilities,
supplies, or equipment.
(4) Use of funds for assisting pregnant and parenting
college students.--An eligible institution of higher
education that receives funding under this subsection shall
use such funds to establish, maintain or operate pregnant and
parenting student services and may use such funding for the
following programs and activities:
(A) Conduct a needs assessment on campus and within the
local community--
(i) to assess pregnancy and parenting resources, located on
the campus or within the local community, that are available
to meet the needs described in subparagraph (B); and
(ii) to set goals for--
(I) improving such resources for pregnant, parenting, and
prospective parenting students; and
(II) improving access to such resources.
(B) Annually assess the performance of the eligible
institution in meeting the following needs of students
enrolled in the eligible institution who are pregnant or are
parents:
(i) The inclusion of maternity coverage and the
availability of riders for additional family members in
student health care.
(ii) Family housing.
(iii) Child care.
(iv) Flexible or alternative academic scheduling, such as
telecommuting programs, to enable pregnant or parenting
students to continue their education or stay in school.
(v) Education to improve parenting skills for mothers and
fathers and to strengthen marriages.
(vi) Maternity and baby clothing, baby food (including
formula), baby furniture, and similar items to assist parents
and prospective parents in meeting the material needs of
their children.
(vii) Post-partum counseling.
(C) Identify public and private service providers, located
on the campus of the eligible institution or within the local
community, that are qualified to meet the needs described in
subparagraph (B), and establishes programs with qualified
providers to meet such needs.
(D) Assist pregnant and parenting students, fathers or
spouses in locating and obtaining services that meet the
needs described in subparagraph (B).
(E) If appropriate, provide referrals for prenatal care and
delivery, infant or foster care, or adoption, to a student
who requests such information. An office shall make such
referrals only to service providers that serve the following
types of individuals:
(i) Parents.
(ii) Prospective parents awaiting adoption.
(iii) Women who are pregnant and plan on parenting or
placing the child for adoption.
(iv) Parenting or prospective parenting couples.
(5) Reporting.--
(A) Annual report by institutions.--
(i) In general.--For each fiscal year that an eligible
institution of higher education receives funds under this
subsection, the eligible institution shall prepare and submit
to the State, by the date determined by the State, a report
that--
(I) itemizes the pregnant and parenting student services
office's expenditures for the fiscal year;
(II) contains a review and evaluation of the performance of
the office in fulfilling the requirements of this section,
using the specific performance criteria or standards
established under subparagraph (B)(i); and
(III) describes the achievement of the office in meeting
the needs listed in paragraph (4)(B) of the students served
by the eligible institution, and the frequency of use of the
office by such students.
(ii) Performance criteria.--Not later than 180 days before
the date the annual report described in clause (i) is
submitted, the State--
(I) shall identify the specific performance criteria or
standards that shall be used to prepare the report; and
(II) may establish the form or format of the report.
(B) Report by state.--The State shall annually prepare and
submit a report on the findings under this subsection,
including the number of eligible institutions of higher
education that were awarded funds and the number of students
served by each pregnant and parenting student services office
receiving funds under this section, to the Secretary.
(c) Support for Pregnant and Parenting Teens.--A State may
use amounts received under a grant under section 10212 to
make funding available to eligible high schools and community
service centers to establish, maintain or operate pregnant
and parenting services in the same general manner and in
accordance with all conditions and requirements described in
subsection (b), except that paragraph (3) of such subsection
shall not apply for purposes of this subsection.
(d) Improving Services for Pregnant Women Who Are Victims
of Domestic Violence, Sexual Violence, Sexual Assault, and
Stalking.--
(1) In general.--A State may use amounts received under a
grant under section 10212 to make funding available tp its
State Attorney General to assist Statewide offices in
providing--
(A) intervention services, accompaniment, and supportive
social services for eligible pregnant women who are victims
of domestic violence, sexual violence, sexual assault, or
stalking.
(B) technical assistance and training (as described in
subsection (c)) relating to violence against eligible
pregnant women to be made available to the following:
(i) Federal, State, tribal, territorial, and local
governments, law enforcement agencies, and courts.
(ii) Professionals working in legal, social service, and
health care settings.
(iii) Nonprofit organizations.
(iv) Faith-based organizations.
(2) Eligibility.--To be eligible for a grant under
paragraph (1), a State Attorney General shall submit an
application to the designated State agency at such time, in
such manner, and containing such information, as specified by
the State.
(3) Technical assistance and training described.--For
purposes of paragraph (1)(B), technical assistance and
training is--
(A) the identification of eligible pregnant women
experiencing domestic violence, sexual violence, sexual
assault, or stalking;
(B) the assessment of the immediate and short-term safety
of such a pregnant woman, the evaluation of the impact of the
violence or stalking on the pregnant woman's health, and the
assistance of the pregnant woman in developing a plan aimed
at preventing further domestic violence, sexual violence,
sexual assault, or stalking, as appropriate;
(C) the maintenance of complete medical or forensic records
that include the documentation of any examination, treatment
given, and referrals made, recording the location and nature
of the pregnant woman's injuries, and the establishment of
mechanisms to ensure the privacy and confidentiality of those
medical records; and
(D) the identification and referral of the pregnant woman
to appropriate public and private nonprofit entities that
provide intervention services, accompaniment, and supportive
social services.
(4) Eligible pregnant woman.--In this subsection, the term
``eligible pregnant woman'' means any woman who is pregnant
on the date
[[Page H2130]]
on which such woman becomes a victim of domestic violence,
sexual violence, sexual assault, or stalking or who was
pregnant during the one-year period before such date.
(e) Public Awareness and Education.--A State may use
amounts received under a grant under section 10212 to make
funding available to increase public awareness and education
concerning any services available to pregnant and parenting
teens and women under this part, or any other resources
available to pregnant and parenting women in keeping with the
intent and purposes of this part. The State shall be
responsible for setting guidelines or limits as to how much
of funding may be utilized for public awareness and education
in any funding award.
SEC. 10214. APPROPRIATIONS.
There is authorized to be appropriated, and there are
appropriated, $25,000,000 for each of fiscal years 2010
through 2019, to carry out this part.
PART III--INDIAN HEALTH CARE IMPROVEMENT
SEC. 10221. INDIAN HEALTH CARE IMPROVEMENT.
(a) In General.--Except as provided in subsection (b), S.
1790 entitled ``A bill to amend the Indian Health Care
Improvement Act to revise and extend that Act, and for other
purposes.'', as reported by the Committee on Indian Affairs
of the Senate in December 2009, is enacted into law.
(b) Amendments.--
(1) Section 119 of the Indian Health Care Improvement Act
(as amended by section 111 of the bill referred to in
subsection (a)) is amended--
(A) in subsection (d)--
(i) in paragraph (2), by striking ``In establishing'' and
inserting ``Subject to paragraphs (3) and (4), in
establishing''; and
(ii) by adding at the end the following:
``(3) Election of indian tribe or tribal organization.--
``(A) In general.--Subparagraph (B) of paragraph (2) shall
not apply in the case of an election made by an Indian tribe
or tribal organization located in a State (other than Alaska)
in which the use of dental health aide therapist services or
midlevel dental health provider services is authorized under
State law to supply such services in accordance with State
law.
``(B) Action by secretary.--On an election by an Indian
tribe or tribal organization under subparagraph (A), the
Secretary, acting through the Service, shall facilitate
implementation of the services elected.
``(4) Vacancies.--The Secretary shall not fill any vacancy
for a certified dentist in a program operated by the Service
with a dental health aide therapist.''; and
(B) by adding at the end the following:
``(e) Effect of Section.--Nothing in this section shall
restrict the ability of the Service, an Indian tribe, or a
tribal organization to participate in any program or to
provide any service authorized by any other Federal law.''.
(2) The Indian Health Care Improvement Act (as amended by
section 134(b) of the bill referred to in subsection (a)) is
amended by striking section 125 (relating to treatment of
scholarships for certain purposes).
(3) Section 806 of the Indian Health Care Improvement Act
(25 U.S.C. 1676) is amended--
(A) by striking ``Any limitation'' and inserting the
following:
``(a) HHS Appropriations.--Any limitation''; and
(B) by adding at the end the following:
``(b) Limitations Pursuant to Other Federal Law.--Any
limitation pursuant to other Federal laws on the use of
Federal funds appropriated to the Service shall apply with
respect to the performance or coverage of abortions.''.
(4) The bill referred to in subsection (a) is amended by
striking section 201.
Subtitle C--Provisions Relating to Title III
SEC. 10301. PLANS FOR A VALUE-BASED PURCHASING PROGRAM FOR
AMBULATORY SURGICAL CENTERS.
(a) In General.--Section 3006 is amended by adding at the
end the following new subsection:
``(f) Ambulatory Surgical Centers.--
``(1) In general.--The Secretary shall develop a plan to
implement a value-based purchasing program for payments under
the Medicare program under title XVIII of the Social Security
Act for ambulatory surgical centers (as described in section
1833(i) of the Social Security Act (42 U.S.C. 1395l(i))).
``(2) Details.--In developing the plan under paragraph (1),
the Secretary shall consider the following issues:
``(A) The ongoing development, selection, and modification
process for measures (including under section 1890 of the
Social Security Act (42 U.S.C. 1395aaa) and section 1890A of
such Act, as added by section 3014), to the extent feasible
and practicable, of all dimensions of quality and efficiency
in ambulatory surgical centers.
``(B) The reporting, collection, and validation of quality
data.
``(C) The structure of value-based payment adjustments,
including the determination of thresholds or improvements in
quality that would substantiate a payment adjustment, the
size of such payments, and the sources of funding for the
value-based bonus payments.
``(D) Methods for the public disclosure of information on
the performance of ambulatory surgical centers.
``(E) Any other issues determined appropriate by the
Secretary.
``(3) Consultation.--In developing the plan under paragraph
(1), the Secretary shall--
``(A) consult with relevant affected parties; and
``(B) consider experience with such demonstrations that the
Secretary determines are relevant to the value-based
purchasing program described in paragraph (1).
``(4) Report to congress.--Not later than January 1, 2011,
the Secretary shall submit to Congress a report containing
the plan developed under paragraph (1).''.
(b) Technical.--Section 3006(a)(2)(A) is amended by
striking clauses (i) and (ii).
SEC. 10302. REVISION TO NATIONAL STRATEGY FOR QUALITY
IMPROVEMENT IN HEALTH CARE.
Section 399HH(a)(2)(B)(iii) of the Public Health Service
Act, as added by section 3011, is amended by inserting
``(taking into consideration the limitations set forth in
subsections (c) and (d) of section 1182 of the Social
Security Act)'' after ``information''.
SEC. 10303. DEVELOPMENT OF OUTCOME MEASURES.
(a) Development.--Section 931 of the Public Health Service
Act, as added by section 3013(a), is amended by adding at the
end the following new subsection:
``(f) Development of Outcome Measures.--
``(1) In general.--The Secretary shall develop, and
periodically update (not less than every 3 years), provider-
level outcome measures for hospitals and physicians, as well
as other providers as determined appropriate by the
Secretary.
``(2) Categories of measures.--The measures developed under
this subsection shall include, to the extent determined
appropriate by the Secretary--
``(A) outcome measurement for acute and chronic diseases,
including, to the extent feasible, the 5 most prevalent and
resource-intensive acute and chronic medical conditions; and
``(B) outcome measurement for primary and preventative
care, including, to the extent feasible, measurements that
cover provision of such care for distinct patient populations
(such as healthy children, chronically ill adults, or infirm
elderly individuals).
``(3) Goals.--In developing such measures, the Secretary
shall seek to--
``(A) address issues regarding risk adjustment,
accountability, and sample size;
``(B) include the full scope of services that comprise a
cycle of care; and
``(C) include multiple dimensions.
``(4) Timeframe.--
``(A) Acute and chronic diseases.--Not later than 24 months
after the date of enactment of this Act, the Secretary shall
develop not less than 10 measures described in paragraph
(2)(A).
``(B) Primary and preventive care.--Not later than 36
months after the date of enactment of this Act, the Secretary
shall develop not less than 10 measures described in
paragraph (2)(B).''.
(b) Hospital-acquired Conditions.--Section 1890A of the
Social Security Act, as amended by section 3013(b), is
amended by adding at the end the following new subsection:
``(f) Hospital Acquired Conditions.--The Secretary shall,
to the extent practicable, publicly report on measures for
hospital-acquired conditions that are currently utilized by
the Centers for Medicare & Medicaid Services for the
adjustment of the amount of payment to hospitals based on
rates of hospital-acquired infections.''.
(c) Clinical Practice Guidelines.--Section 304(b) of the
Medicare Improvements for Patients and Providers Act of 2008
(Public Law 110-275) is amended by adding at the end the
following new paragraph:
``(4) Identification.--
``(A) In general.--Following receipt of the report
submitted under paragraph (2), and not less than every 3
years thereafter, the Secretary shall contract with the
Institute to employ the results of the study performed under
paragraph (1) and the best methods identified by the
Institute for the purpose of identifying existing and new
clinical practice guidelines that were developed using such
best methods, including guidelines listed in the National
Guideline Clearinghouse.
``(B) Consultation.--In carrying out the identification
process under subparagraph (A), the Secretary shall allow for
consultation with professional societies, voluntary health
care organizations, and expert panels.''.
SEC. 10304. SELECTION OF EFFICIENCY MEASURES.
Sections 1890(b)(7) and 1890A of the Social Security Act,
as added by section 3014, are amended by striking ``quality''
each place it appears and inserting ``quality and
efficiency''.
SEC. 10305. DATA COLLECTION; PUBLIC REPORTING.
Section 399II(a) of the Public Health Service Act, as added
by section 3015, is amended to read as follows:
``(a) In General.--
``(1) Establishment of strategic framework.--The Secretary
shall establish and implement an overall strategic framework
to carry out the public reporting of performance information,
as described in section 399JJ. Such strategic framework may
include methods and related timelines for implementing
nationally consistent data collection, data aggregation, and
analysis methods.
``(2) Collection and aggregation of data.--The Secretary
shall collect and aggregate consistent data on quality and
resource use measures from information systems used to
support health care delivery, and may award grants or
contracts for this purpose. The Secretary shall align such
collection and aggregation efforts with the requirements and
assistance regarding the expansion of health information
technology systems, the interoperability of such technology
systems, and related standards that are in effect on the date
of enactment of the Patient Protection and Affordable Care
Act.
``(3) Scope.--The Secretary shall ensure that the data
collection, data aggregation, and analysis systems described
in paragraph (1) involve
[[Page H2131]]
an increasingly broad range of patient populations,
providers, and geographic areas over time.''.
SEC. 10306. IMPROVEMENTS UNDER THE CENTER FOR MEDICARE AND
MEDICAID INNOVATION.
Section 1115A of the Social Security Act, as added by
section 3021, is amended--
(1) in subsection (a), by inserting at the end the
following new paragraph:
``(5) Testing within certain geographic areas.--For
purposes of testing payment and service delivery models under
this section, the Secretary may elect to limit testing of a
model to certain geographic areas.'';
(2) in subsection (b)(2)--
(A) in subparagraph (A)--
(i) in the second sentence, by striking ``the preceding
sentence may include'' and inserting ``this subparagraph may
include, but are not limited to,''; and
(ii) by inserting after the first sentence the following
new sentence: ``The Secretary shall focus on models expected
to reduce program costs under the applicable title while
preserving or enhancing the quality of care received by
individuals receiving benefits under such title.'';
(B) in subparagraph (B), by adding at the end the following
new clauses:
``(xix) Utilizing, in particular in entities located in
medically underserved areas and facilities of the Indian
Health Service (whether operated by such Service or by an
Indian tribe or tribal organization (as those terms are
defined in section 4 of the Indian Health Care Improvement
Act)), telehealth services--
``(I) in treating behavioral health issues (such as post-
traumatic stress disorder) and stroke; and
``(II) to improve the capacity of non-medical providers and
non-specialized medical providers to provide health services
for patients with chronic complex conditions.
``(xx) Utilizing a diverse network of providers of services
and suppliers to improve care coordination for applicable
individuals described in subsection (a)(4)(A)(i) with 2 or
more chronic conditions and a history of prior-year
hospitalization through interventions developed under the
Medicare Coordinated Care Demonstration Project under section
4016 of the Balanced Budget Act of 1997 (42 U.S.C. 1395b-1
note).''; and
(C) in subparagraph (C), by adding at the end the following
new clause:
``(viii) Whether the model demonstrates effective linkage
with other public sector or private sector payers.'';
(3) in subsection (b)(4), by adding at the end the
following new subparagraph:
``(C) Measure selection.--To the extent feasible, the
Secretary shall select measures under this paragraph that
reflect national priorities for quality improvement and
patient-centered care consistent with the measures described
in 1890(b)(7)(B).''; and
(4) in subsection (c)--
(A) in paragraph (1)(B), by striking ``care and reduce
spending; and'' and inserting ``patient care without
increasing spending;'';
(B) in paragraph (2), by striking ``reduce program spending
under applicable titles.'' and inserting ``reduce (or would
not result in any increase in) net program spending under
applicable titles; and''; and
(C) by adding at the end the following:
``(3) the Secretary determines that such expansion would
not deny or limit the coverage or provision of benefits under
the applicable title for applicable individuals.
In determining which models or demonstration projects to
expand under the preceding sentence, the Secretary shall
focus on models and demonstration projects that improve the
quality of patient care and reduce spending.''.
SEC. 10307. IMPROVEMENTS TO THE MEDICARE SHARED SAVINGS
PROGRAM.
Section 1899 of the Social Security Act, as added by
section 3022, is amended by adding at the end the following
new subsections:
``(i) Option To Use Other Payment Models.--
``(1) In general.--If the Secretary determines appropriate,
the Secretary may use any of the payment models described in
paragraph (2) or (3) for making payments under the program
rather than the payment model described in subsection (d).
``(2) Partial capitation model.--
``(A) In general.--Subject to subparagraph (B), a model
described in this paragraph is a partial capitation model in
which an ACO is at financial risk for some, but not all, of
the items and services covered under parts A and B, such as
at risk for some or all physicians' services or all items and
services under part B. The Secretary may limit a partial
capitation model to ACOs that are highly integrated systems
of care and to ACOs capable of bearing risk, as determined to
be appropriate by the Secretary.
``(B) No additional program expenditures.--Payments to an
ACO for items and services under this title for beneficiaries
for a year under the partial capitation model shall be
established in a manner that does not result in spending more
for such ACO for such beneficiaries than would otherwise be
expended for such ACO for such beneficiaries for such year if
the model were not implemented, as estimated by the
Secretary.
``(3) Other payment models.--
``(A) In general.--Subject to subparagraph (B), a model
described in this paragraph is any payment model that the
Secretary determines will improve the quality and efficiency
of items and services furnished under this title.
``(B) No additional program expenditures.--Subparagraph (B)
of paragraph (2) shall apply to a payment model under
subparagraph (A) in a similar manner as such subparagraph (B)
applies to the payment model under paragraph (2).
``(j) Involvement in Private Payer and Other Third Party
Arrangements.--The Secretary may give preference to ACOs who
are participating in similar arrangements with other payers.
``(k) Treatment of Physician Group Practice
Demonstration.--During the period beginning on the date of
the enactment of this section and ending on the date the
program is established, the Secretary may enter into an
agreement with an ACO under the demonstration under section
1866A, subject to rebasing and other modifications deemed
appropriate by the Secretary.''.
SEC. 10308. REVISIONS TO NATIONAL PILOT PROGRAM ON PAYMENT
BUNDLING.
(a) In General.--Section 1866D of the Social Security Act,
as added by section 3023, is amended--
(1) in paragraph (a)(2)(B), in the matter preceding clause
(i), by striking ``8 conditions'' and inserting ``10
conditions'';
(2) by striking subsection (c)(1)(B) and inserting the
following:
``(B) Expansion.--The Secretary may, at any point after
January 1, 2016, expand the duration and scope of the pilot
program, to the extent determined appropriate by the
Secretary, if--
``(i) the Secretary determines that such expansion is
expected to--
``(I) reduce spending under title XVIII of the Social
Security Act without reducing the quality of care; or
``(II) improve the quality of care and reduce spending;
``(ii) the Chief Actuary of the Centers for Medicare &
Medicaid Services certifies that such expansion would reduce
program spending under such title XVIII; and
``(iii) the Secretary determines that such expansion would
not deny or limit the coverage or provision of benefits under
this title for individuals.''; and
(3) by striking subsection (g) and inserting the following
new subsection:
``(g) Application of Pilot Program to Continuing Care
Hospitals.--
``(1) In general.--In conducting the pilot program, the
Secretary shall apply the provisions of the program so as to
separately pilot test the continuing care hospital model.
``(2) Special rules.--In pilot testing the continuing care
hospital model under paragraph (1), the following rules shall
apply:
``(A) Such model shall be tested without the limitation to
the conditions selected under subsection (a)(2)(B).
``(B) Notwithstanding subsection (a)(2)(D), an episode of
care shall be defined as the full period that a patient stays
in the continuing care hospital plus the first 30 days
following discharge from such hospital.
``(3) Continuing care hospital defined.--In this
subsection, the term `continuing care hospital' means an
entity that has demonstrated the ability to meet patient care
and patient safety standards and that provides under common
management the medical and rehabilitation services provided
in inpatient rehabilitation hospitals and units (as defined
in section 1886(d)(1)(B)(ii)), long term care hospitals (as
defined in section 1886(d)(1)(B)(iv)(I)), and skilled nursing
facilities (as defined in section 1819(a)) that are located
in a hospital described in section 1886(d).''.
(b) Technical Amendments.--
(1) Section 3023 is amended by striking ``1886C'' and
inserting ``1866C''.
(2) Title XVIII of the Social Security Act is amended by
redesignating section 1866D, as added by section 3024, as
section 1866E.
SEC. 10309. REVISIONS TO HOSPITAL READMISSIONS REDUCTION
PROGRAM.
Section 1886(q)(1) of the Social Security Act, as added by
section 3025, in the matter preceding subparagraph (A), is
amended by striking ``the Secretary shall reduce the
payments'' and all that follows through ``the product of''
and inserting ``the Secretary shall make payments (in
addition to the payments described in paragraph (2)(A)(ii))
for such a discharge to such hospital under subsection (d)
(or section 1814(b)(3), as the case may be) in an amount
equal to the product of''.
SEC. 10310. REPEAL OF PHYSICIAN PAYMENT UPDATE.
The provisions of, and the amendment made by, section 3101
are repealed.
SEC. 10311. REVISIONS TO EXTENSION OF AMBULANCE ADD-ONS.
(a) Ground Ambulance.--Section 1834(l)(13)(A) of the Social
Security Act (42 U.S.C. 1395m(l)(13)(A)), as amended by
section 3105(a), is further amended--
(1) in the matter preceding clause (i)--
(A) by striking ``2007, for'' and inserting ``2007, and
for''; and
(B) by striking ``2010, and for such services furnished on
or after April 1, 2010, and before January 1, 2011'' and
inserting ``2011''; and
(2) in each of clauses (i) and (ii)--
(A) by striking ``, and on or after April 1, 2010, and
before January 1, 2011'' each place it appears; and
(B) by striking ``January 1, 2010'' and inserting ``January
1, 2011'' each place it appears.
(b) Air Ambulance.--Section 146(b)(1) of the Medicare
Improvements for Patients and Providers Act of 2008 (Public
Law 110-275), as amended by section 3105(b), is further
amended by striking ``December 31, 2009, and during the
period beginning on April 1, 2010, and ending on January 1,
2011'' and inserting ``December 31, 2010''.
(c) Super Rural Ambulance.--Section 1834(l)(12)(A) of the
Social Security Act (42 U.S.C. 1395m(l)(12)(A)), as amended
by section 3105(c), is further amended by striking ``2010,
and on or after April 1, 2010, and before January 1, 2011''
and inserting ``2011''.
[[Page H2132]]
SEC. 10312. CERTAIN PAYMENT RULES FOR LONG-TERM CARE HOSPITAL
SERVICES AND MORATORIUM ON THE ESTABLISHMENT OF
CERTAIN HOSPITALS AND FACILITIES.
(a) Certain Payment Rules.--Section 114(c) of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395ww
note), as amended by section 4302(a) of the American Recovery
and Reinvestment Act (Public Law 111-5) and section 3106(a)
of this Act, is further amended by striking ``4-year period''
each place it appears and inserting ``5-year period''.
(b) Moratorium.--Section 114(d) of such Act (42 U.S.C.
1395ww note), as amended by section 3106(b) of this Act, in
the matter preceding subparagraph (A), is amended by striking
``4-year period'' and inserting ``5-year period''.
SEC. 10313. REVISIONS TO THE EXTENSION FOR THE RURAL
COMMUNITY HOSPITAL DEMONSTRATION PROGRAM.
(a) In General.--Subsection (g) of section 410A of the
Medicare Prescription Drug, Improvement, and Modernization
Act of 2003 (Public Law 108-173; 117 Stat. 2272), as added by
section 3123(a) of this Act, is amended to read as follows:
``(g) Five-Year Extension of Demonstration Program.--
``(1) In general.--Subject to the succeeding provisions of
this subsection, the Secretary shall conduct the
demonstration program under this section for an additional 5-
year period (in this section referred to as the `5-year
extension period') that begins on the date immediately
following the last day of the initial 5-year period under
subsection (a)(5).
``(2) Expansion of demonstration states.--Notwithstanding
subsection (a)(2), during the 5-year extension period, the
Secretary shall expand the number of States with low
population densities determined by the Secretary under such
subsection to 20. In determining which States to include in
such expansion, the Secretary shall use the same criteria and
data that the Secretary used to determine the States under
such subsection for purposes of the initial 5-year period.
``(3) Increase in maximum number of hospitals participating
in the demonstration program.--Notwithstanding subsection
(a)(4), during the 5-year extension period, not more than 30
rural community hospitals may participate in the
demonstration program under this section.
``(4) Hospitals in demonstration program on date of
enactment.--In the case of a rural community hospital that is
participating in the demonstration program under this section
as of the last day of the initial 5-year period, the
Secretary--
``(A) shall provide for the continued participation of such
rural community hospital in the demonstration program during
the 5-year extension period unless the rural community
hospital makes an election, in such form and manner as the
Secretary may specify, to discontinue such participation; and
``(B) in calculating the amount of payment under subsection
(b) to the rural community hospital for covered inpatient
hospital services furnished by the hospital during such 5-
year extension period, shall substitute, under paragraph
(1)(A) of such subsection--
``(i) the reasonable costs of providing such services for
discharges occurring in the first cost reporting period
beginning on or after the first day of the 5-year extension
period, for
``(ii) the reasonable costs of providing such services for
discharges occurring in the first cost reporting period
beginning on or after the implementation of the demonstration
program.''.
(b) Conforming Amendments.--Subsection (a)(5) of section
410A of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (Public Law 108-173; 117 Stat.
2272), as amended by section 3123(b) of this Act, is amended
by striking ``1-year extension'' and inserting ``5-year
extension''.
SEC. 10314. ADJUSTMENT TO LOW-VOLUME HOSPITAL PROVISION.
Section 1886(d)(12) of the Social Security Act (42 U.S.C.
1395ww(d)(12), as amended by section 3125, is amended--
(1) in subparagraph (C)(i), by striking ``1,500
discharges'' and inserting ``1,600 discharges''; and
(2) in subparagraph (D), by striking ``1,500 discharges''
and inserting ``1,600 discharges''.
SEC. 10315. REVISIONS TO HOME HEALTH CARE PROVISIONS.
(a) Rebasing.--Section 1895(b)(3)(A)(iii) of the Social
Security Act, as added by section 3131, is amended--
(1) in the clause heading, by striking ``2013'' and
inserting ``2014'';
(2) in subclause (I), by striking ``2013'' and inserting
``2014''; and
(3) in subclause (II), by striking ``2016'' and inserting
``2017''.
(b) Revision of Home Health Study and Report.--Section
3131(d) is amended to read as follows:
``(d) Study and Report on the Development of Home Health
Payment Revisions in Order to Ensure Access to Care and
Payment for Severity of Illness.--
``(1) In general.--The Secretary of Health and Human
Services (in this section referred to as the `Secretary')
shall conduct a study on home health agency costs involved
with providing ongoing access to care to low-income Medicare
beneficiaries or beneficiaries in medically underserved
areas, and in treating beneficiaries with varying levels of
severity of illness. In conducting the study, the Secretary
may analyze items such as the following:
``(A) Methods to potentially revise the home health
prospective payment system under section 1895 of the Social
Security Act (42 U.S.C. 1395fff) to account for costs related
to patient severity of illness or to improving beneficiary
access to care, such as--
``(i) payment adjustments for services that may involve
additional or fewer resources;
``(ii) changes to reflect resources involved with providing
home health services to low-income Medicare beneficiaries or
Medicare beneficiaries residing in medically underserved
areas;
``(iii) ways outlier payments might be revised to reflect
costs of treating Medicare beneficiaries with high levels of
severity of illness; and
``(iv) other issues determined appropriate by the
Secretary.
``(B) Operational issues involved with potential
implementation of potential revisions to the home health
payment system, including impacts for both home health
agencies and administrative and systems issues for the
Centers for Medicare & Medicaid Services, and any possible
payment vulnerabilities associated with implementing
potential revisions.
``(C) Whether additional research might be needed.
``(D) Other items determined appropriate by the Secretary.
``(2) Considerations.--In conducting the study under
paragraph (1), the Secretary may consider whether patient
severity of illness and access to care could be measured by
factors, such as--
``(A) population density and relative patient access to
care;
``(B) variations in service costs for providing care to
individuals who are dually eligible under the Medicare and
Medicaid programs;
``(C) the presence of severe or chronic diseases, which
might be measured by multiple, discontinuous home health
episodes;
``(D) poverty status, such as evidenced by the receipt of
Supplemental Security Income under title XVI of the Social
Security Act; and
``(E) other factors determined appropriate by the
Secretary.
``(3) Report.--Not later than March 1, 2014, the Secretary
shall submit to Congress a report on the study conducted
under paragraph (1), together with recommendations for such
legislation and administrative action as the Secretary
determines appropriate.
``(4) Consultations.--In conducting the study under
paragraph (1), the Secretary shall consult with appropriate
stakeholders, such as groups representing home health
agencies and groups representing Medicare beneficiaries.
``(5) Medicare demonstration project based on the results
of the study.--
``(A) In general.--Subject to subparagraph (D), taking into
account the results of the study conducted under paragraph
(1), the Secretary may, as determined appropriate, provide
for a demonstration project to test whether making payment
adjustments for home health services under the Medicare
program would substantially improve access to care for
patients with high severity levels of illness or for low-
income or underserved Medicare beneficiaries.
``(B) Waiving budget neutrality.--The Secretary shall not
reduce the standard prospective payment amount (or amounts)
under section 1895 of the Social Security Act (42 U.S.C.
1395fff) applicable to home health services furnished during
a period to offset any increase in payments during such
period resulting from the application of the payment
adjustments under subparagraph (A).
``(C) No effect on subsequent periods.--A payment
adjustment resulting from the application of subparagraph (A)
for a period--
``(i) shall not apply to payments for home health services
under title XVIII after such period; and
``(ii) shall not be taken into account in calculating the
payment amounts applicable for such services after such
period.
``(D) Duration.--If the Secretary determines it appropriate
to conduct the demonstration project under this subsection,
the Secretary shall conduct the project for a four year
period beginning not later than January 1, 2015.
``(E) Funding.--The Secretary shall provide for the
transfer from the Federal Hospital Insurance Trust Fund under
section 1817 of the Social Security Act (42 U.S.C. 1395i) and
the Federal Supplementary Medical Insurance Trust Fund
established under section 1841 of such Act (42 U.S.C. 1395t),
in such proportion as the Secretary determines appropriate,
of $500,000,000 for the period of fiscal years 2015 through
2018. Such funds shall be made available for the study
described in paragraph (1) and the design, implementation and
evaluation of the demonstration described in this paragraph.
Amounts available under this subparagraph shall be available
until expended.
``(F) Evaluation and report.--If the Secretary determines
it appropriate to conduct the demonstration project under
this subsection, the Secretary shall--
``(i) provide for an evaluation of the project; and
``(ii) submit to Congress, by a date specified by the
Secretary, a report on the project.
``(G) Administration.--Chapter 35 of title 44, United
States Code, shall not apply with respect to this
subsection.''.
SEC. 10316. MEDICARE DSH.
Section 1886(r)(2)(B) of the Social Security Act, as added
by section 3133, is amended--
(1) in clause (i)--
(A) in the matter preceding subclause (I), by striking
``(divided by 100)'';
(B) in subclause (I), by striking ``2012'' and inserting
``2013'';
(C) in subclause (II), by striking the period at the end
and inserting a comma; and
(D) by adding at the end the following flush matter:
``minus 1.5 percentage points.''.
(2) in clause (ii)--
(A) in the matter preceding subclause (I), by striking
``(divided by 100)'';
(B) in subclause (I), by striking ``2012'' and inserting
``2013'';
[[Page H2133]]
(C) in subclause (II), by striking the period at the end
and inserting a comma; and
(D) by adding at the end the following flush matter:
``and, for each of 2018 and 2019, minus 1.5 percentage
points.''.
SEC. 10317. REVISIONS TO EXTENSION OF SECTION 508 HOSPITAL
PROVISIONS.
Section 3137(a) is amended to read as follows:
``(a) Extension.--
``(1) In general.--Subsection (a) of section 106 of
division B of the Tax Relief and Health Care Act of 2006 (42
U.S.C. 1395 note), as amended by section 117 of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-
173) and section 124 of the Medicare Improvements for
Patients and Providers Act of 2008 (Public Law 110-275), is
amended by striking `September 30, 2009' and inserting
`September 30, 2010'.
``(2) Special rule for fiscal year 2010.--
``(A) In general.--Subject to subparagraph (B), for
purposes of implementation of the amendment made by paragraph
(1), including (notwithstanding paragraph (3) of section
117(a) of the Medicare, Medicaid and SCHIP Extension Act of
2007 (Public Law 110-173), as amended by section 124(b) of
the Medicare Improvements for Patients and Providers Act of
2008 (Public Law 110-275)) for purposes of the implementation
of paragraph (2) of such section 117(a), during fiscal year
2010, the Secretary of Health and Human Services (in this
subsection referred to as the `Secretary') shall use the
hospital wage index that was promulgated by the Secretary in
the Federal Register on August 27, 2009 (74 Fed. Reg. 43754),
and any subsequent corrections.
``(B) Exception.--Beginning on April 1, 2010, in
determining the wage index applicable to hospitals that
qualify for wage index reclassification, the Secretary shall
include the average hourly wage data of hospitals whose
reclassification was extended pursuant to the amendment made
by paragraph (1) only if including such data results in a
higher applicable reclassified wage index.
``(3) Adjustment for certain hospitals in fiscal year
2010.--
``(A) In general.--In the case of a subsection (d) hospital
(as defined in subsection (d)(1)(B) of section 1886 of the
Social Security Act (42 U.S.C. 1395ww)) with respect to
which--
``(i) a reclassification of its wage index for purposes of
such section was extended pursuant to the amendment made by
paragraph (1); and
``(ii) the wage index applicable for such hospital for the
period beginning on October 1, 2009, and ending on March 31,
2010, was lower than for the period beginning on April 1,
2010, and ending on September 30, 2010, by reason of the
application of paragraph (2)(B);
the Secretary shall pay such hospital an additional payment
that reflects the difference between the wage index for such
periods.
``(B) Timeframe for payments.--The Secretary shall make
payments required under subparagraph by not later than
December 31, 2010.''.
SEC. 10318. REVISIONS TO TRANSITIONAL EXTRA BENEFITS UNDER
MEDICARE ADVANTAGE.
Section 1853(p)(3)(A) of the Social Security Act, as added
by section 3201(h), is amended by inserting ``in 2009''
before the period at the end.
SEC. 10319. REVISIONS TO MARKET BASKET ADJUSTMENTS.
(a) Inpatient Acute Hospitals.--Section 1886(b)(3)(B)(xii)
of the Social Security Act, as added by section 3401(a), is
amended--
(1) in subclause (I), by striking ``and'' at the end;
(2) by redesignating subclause (II) as subclause (III);
(3) by inserting after subclause (II) the following new
subclause:
``(II) for each of fiscal years 2012 and 2013, by 0.1
percentage point; and''; and
(4) in subclause (III), as redesignated by paragraph (2),
by striking ``2012'' and inserting ``2014''.
(b) Long-term Care Hospitals.--Section 1886(m)(4) of the
Social Security Act, as added by section 3401(c), is
amended--
(1) in subparagraph (A)--
(A) in clause (i)--
(i) by striking ``each of rate years 2010 and 2011'' and
inserting ``rate year 2010''; and
(ii) by striking ``and'' at the end;
(B) by redesignating clause (ii) as clause (iv);
(C) by inserting after clause (i) the following new
clauses:
``(ii) for rate year 2011, 0.50 percentage point;
``(iii) for each of the rate years beginning in 2012 and
2013, 0.1 percentage point; and''; and
(D) in clause (iv), as redesignated by subparagraph (B), by
striking ``2012'' and inserting ``2014''; and
(2) in subparagraph (B), by striking ``(A)(ii)'' and
inserting ``(A)(iv)''.
(c) Inpatient Rehabilitation Facilities.--Section
1886(j)(3)(D)(i) of the Social Security Act, as added by
section 3401(d), is amended--
(1) in subclause (I), by striking ``and'' at the end;
(2) by redesignating subclause (II) as subclause (III);
(3) by inserting after subclause (II) the following new
subclause:
``(II) for each of fiscal years 2012 and 2013, 0.1
percentage point; and''; and
(4) in subclause (III), as redesignated by paragraph (2),
by striking ``2012'' and inserting ``2014''.
(d) Home Health Agencies.--Section 1895(b)(3)(B)(vi)(II) of
such Act, as added by section 3401(e), is amended by striking
``and 2012'' and inserting ``, 2012, and 2013''.
(e) Psychiatric Hospitals.--Section 1886(s)(3)(A) of the
Social Security Act, as added by section 3401(f), is
amended--
(1) in clause (i), by striking ``and'' at the end;
(2) by redesignating clause (ii) as clause (iii);
(3) by inserting after clause (ii) the following new
clause:
``(ii) for each of the rate years beginning in 2012 and
2013, 0.1 percentage point; and''; and
(4) in clause (iii), as redesignated by paragraph (2), by
striking ``2012'' and inserting ``2014''.
(f) Hospice Care.--Section 1814(i)(1)(C) of the Social
Security Act (42 U.S.C. 1395f(i)(1)(C)), as amended by
section 3401(g), is amended--
(1) in clause (iv)(II), by striking ``0.5'' and inserting
``0.3''; and
(2) in clause (v), in the matter preceding subclause (I),
by striking ``0.5'' and inserting ``0.3''.
(g) Outpatient Hospitals.--Section 1833(t)(3)(G)(i) of the
Social Security Act, as added by section 3401(i), is
amended--
(1) in subclause (I), by striking ``and'' at the end;
(2) by redesignating subclause (II) as subclause (III);
(3) by inserting after subclause (II) the following new
subclause:
``(II) for each of 2012 and 2013, 0.1 percentage point;
and''; and
(4) in subclause (III), as redesignated by paragraph (2),
by striking ``2012'' and inserting ``2014''.
SEC. 10320. EXPANSION OF THE SCOPE OF, AND ADDITIONAL
IMPROVEMENTS TO, THE INDEPENDENT MEDICARE
ADVISORY BOARD.
(a) In General.--Section 1899A of the Social Security Act,
as added by section 3403, is amended--
(1) in subsection (c)--
(A) in paragraph (1)(B), by adding at the end the following
new sentence: ``In any year (beginning with 2014) that the
Board is not required to submit a proposal under this
section, the Board shall submit to Congress an advisory
report on matters related to the Medicare program.'';
(B) in paragraph (2)(A)--
(i) in clause (iv), by inserting ``or the full premium
subsidy under section 1860D-14(a)'' before the period at the
end of the last sentence; and
(ii) by adding at the end the following new clause:
``(vii) If the Chief Actuary of the Centers for Medicare &
Medicaid Services has made a determination described in
subsection (e)(3)(B)(i)(II) in the determination year, the
proposal shall be designed to help reduce the growth rate
described in paragraph (8) while maintaining or enhancing
beneficiary access to quality care under this title.'';
(C) in paragraph (2)(B)--
(i) in clause (v), by striking ``and'' at the end;
(ii) in clause (vi), by striking the period at the end and
inserting ``; and''; and
(iii) by adding at the end the following new clause:
``(vii) take into account the data and findings contained
in the annual reports under subsection (n) in order to
develop proposals that can most effectively promote the
delivery of efficient, high quality care to Medicare
beneficiaries.'';
(D) in paragraph (3)--
(i) in the heading, by striking ``Transmission of board
proposal to president'' and inserting ``Submission of board
proposal to congress and the president'';
(ii) in subparagraph (A)(i), by striking ``transmit a
proposal under this section to the President'' and insert
``submit a proposal under this section to Congress and the
President''; and
(iii) in subparagraph (A)(ii)--
(I) in subclause (I), by inserting ``or'' at the end;
(II) in subclause (II), by striking ``; or'' and inserting
a period; and
(III) by striking subclause (III);
(E) in paragraph (4)--
(i) by striking ``the Board under paragraph (3)(A)(i) or'';
and
(ii) by striking ``immediately'' and inserting ``within 2
days'';
(F) in paragraph (5)--
(i) by striking ``to but'' and inserting ``but''; and
(ii) by inserting ``Congress and'' after ``submit a
proposal to''; and
(G) in paragraph (6)(B)(i), by striking ``per unduplicated
enrollee'' and inserting ``(calculated as the sum of per
capita spending under each of parts A, B, and D)'';
(2) in subsection (d)--
(A) in paragraph (1)(A)--
(i) by inserting ``the Board or'' after ``a proposal is
submitted by''; and
(ii) by inserting ``subsection (c)(3)(A)(i) or'' after
``the Senate under''; and
(B) in paragraph (2)(A), by inserting ``the Board or''
after ``a proposal is submitted by'';
(3) in subsection (e)--
(A) in paragraph (1), by inserting ``the Board or'' after
``a proposal submitted by''; and
(B) in paragraph (3)--
(i) by striking ``Exception.--The Secretary shall not be
required to implement the recommendations contained in a
proposal submitted in a proposal year by'' and inserting
``Exceptions.--
``(A) In general.--The Secretary shall not implement the
recommendations contained in a proposal submitted in a
proposal year by the Board or'';
(ii) by redesignating subparagraphs (A) and (B) as clauses
(i) and (ii), respectively, and indenting appropriately; and
(iii) by adding at the end the following new subparagraph:
``(B) Limited additional exception.--
``(i) In general.--Subject to clause (ii), the Secretary
shall not implement the recommendations contained in a
proposal submitted by the Board or the President to Congress
pursuant to this section in a proposal year (beginning with
proposal year 2019) if--
[[Page H2134]]
``(I) the Board was required to submit a proposal to
Congress under this section in the year preceding the
proposal year; and
``(II) the Chief Actuary of the Centers for Medicare &
Medicaid Services makes a determination in the determination
year that the growth rate described in subsection (c)(8)
exceeds the growth rate described in subsection (c)(6)(A)(i).
``(ii) Limited additional exception may not be applied in
two consecutive years.--This subparagraph shall not apply if
the recommendations contained in a proposal submitted by the
Board or the President to Congress pursuant to this section
in the year preceding the proposal year were not required to
be implemented by reason of this subparagraph.
``(iii) No affect on requirement to submit proposals or for
congressional consideration of proposals.--Clause (i) and
(ii) shall not affect--
``(I) the requirement of the Board or the President to
submit a proposal to Congress in a proposal year in
accordance with the provisions of this section; or
``(II) Congressional consideration of a legislative
proposal (described in subsection (c)(3)(B)(iv)) contained
such a proposal in accordance with subsection (d).'';
(4) in subsection (f)(3)(B)--
(A) by striking ``or advisory reports to Congress'' and
inserting ``, advisory reports, or advisory
recommendations''; and
(B) by inserting ``or produce the public report under
subsection (n)'' after ``this section''; and
(5) by adding at the end the following new subsections:
``(n) Annual Public Report.--
``(1) In general.--Not later than July 1, 2014, and
annually thereafter, the Board shall produce a public report
containing standardized information on system-wide health
care costs, patient access to care, utilization, and quality-
of-care that allows for comparison by region, types of
services, types of providers, and both private payers and the
program under this title.
``(2) Requirements.--Each report produced pursuant to
paragraph (1) shall include information with respect to the
following areas:
``(A) The quality and costs of care for the population at
the most local level determined practical by the Board (with
quality and costs compared to national benchmarks and
reflecting rates of change, taking into account quality
measures described in section 1890(b)(7)(B)).
``(B) Beneficiary and consumer access to care, patient and
caregiver experience of care, and the cost-sharing or out-of-
pocket burden on patients.
``(C) Epidemiological shifts and demographic changes.
``(D) The proliferation, effectiveness, and utilization of
health care technologies, including variation in provider
practice patterns and costs.
``(E) Any other areas that the Board determines affect
overall spending and quality of care in the private sector.
``(o) Advisory Recommendations for Non-Federal Health Care
Programs.--
``(1) In general.--Not later than January 15, 2015, and at
least once every two years thereafter, the Board shall submit
to Congress and the President recommendations to slow the
growth in national health expenditures (excluding
expenditures under this title and in other Federal health
care programs) while preserving or enhancing quality of care,
such as recommendations--
``(A) that the Secretary or other Federal agencies can
implement administratively;
``(B) that may require legislation to be enacted by
Congress in order to be implemented;
``(C) that may require legislation to be enacted by State
or local governments in order to be implemented;
``(D) that private sector entities can voluntarily
implement; and
``(E) with respect to other areas determined appropriate by
the Board.
``(2) Coordination.--In making recommendations under
paragraph (1), the Board shall coordinate such
recommendations with recommendations contained in proposals
and advisory reports produced by the Board under subsection
(c).
``(3) Available to public.--The Board shall make
recommendations submitted to Congress and the President under
this subsection available to the public.''.
(b) Name Change.--Any reference in the provisions of, or
amendments made by, section 3403 to the ``Independent
Medicare Advisory Board'' shall be deemed to be a reference
to the ``Independent Payment Advisory Board''.
(c) Rule of Construction.--Nothing in the amendments made
by this section shall preclude the Independent Medicare
Advisory Board, as established under section 1899A of the
Social Security Act (as added by section 3403), from solely
using data from public or private sources to carry out the
amendments made by subsection (a)(4).
SEC. 10321. REVISION TO COMMUNITY HEALTH TEAMS.
Section 3502(c)(2)(A) is amended by inserting ``or other
primary care providers'' after ``physicians''.
SEC. 10322. QUALITY REPORTING FOR PSYCHIATRIC HOSPITALS.
(a) In General.--Section 1886(s) of the Social Security
Act, as added by section 3401(f), is amended by adding at the
end the following new paragraph:
``(4) Quality reporting.--
``(A) Reduction in update for failure to report.--
``(i) In general.--Under the system described in paragraph
(1), for rate year 2014 and each subsequent rate year, in the
case of a psychiatric hospital or psychiatric unit that does
not submit data to the Secretary in accordance with
subparagraph (C) with respect to such a rate year, any annual
update to a standard Federal rate for discharges for the
hospital during the rate year, and after application of
paragraph (2), shall be reduced by 2 percentage points.
``(ii) Special rule.--The application of this subparagraph
may result in such annual update being less than 0.0 for a
rate year, and may result in payment rates under the system
described in paragraph (1) for a rate year being less than
such payment rates for the preceding rate year.
``(B) Noncumulative application.--Any reduction under
subparagraph (A) shall apply only with respect to the rate
year involved and the Secretary shall not take into account
such reduction in computing the payment amount under the
system described in paragraph (1) for a subsequent rate year.
``(C) Submission of quality data.--For rate year 2014 and
each subsequent rate year, each psychiatric hospital and
psychiatric unit shall submit to the Secretary data on
quality measures specified under subparagraph (D). Such data
shall be submitted in a form and manner, and at a time,
specified by the Secretary for purposes of this subparagraph.
``(D) Quality measures.--
``(i) In general.--Subject to clause (ii), any measure
specified by the Secretary under this subparagraph must have
been endorsed by the entity with a contract under section
1890(a).
``(ii) Exception.--In the case of a specified area or
medical topic determined appropriate by the Secretary for
which a feasible and practical measure has not been endorsed
by the entity with a contract under section 1890(a), the
Secretary may specify a measure that is not so endorsed as
long as due consideration is given to measures that have been
endorsed or adopted by a consensus organization identified by
the Secretary.
``(iii) Time frame.--Not later than October 1, 2012, the
Secretary shall publish the measures selected under this
subparagraph that will be applicable with respect to rate
year 2014.
``(E) Public availability of data submitted.--The Secretary
shall establish procedures for making data submitted under
subparagraph (C) available to the public. Such procedures
shall ensure that a psychiatric hospital and a psychiatric
unit has the opportunity to review the data that is to be
made public with respect to the hospital or unit prior to
such data being made public. The Secretary shall report
quality measures that relate to services furnished in
inpatient settings in psychiatric hospitals and psychiatric
units on the Internet website of the Centers for Medicare &
Medicaid Services.''.
(b) Conforming Amendment.--Section 1890(b)(7)(B)(i)(I) of
the Social Security Act, as added by section 3014, is amended
by inserting ``1886(s)(4)(D),'' after ``1886(o)(2),''.
SEC. 10323. MEDICARE COVERAGE FOR INDIVIDUALS EXPOSED TO
ENVIRONMENTAL HEALTH HAZARDS.
(a) In General.--Title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) is amended by inserting after section
1881 the following new section:
``SEC. 1881A. MEDICARE COVERAGE FOR INDIVIDUALS EXPOSED TO
ENVIRONMENTAL HEALTH HAZARDS.
``(a) Deeming of Individuals as Eligible for Medicare
Benefits.--
``(1) In general.--For purposes of eligibility for benefits
under this title, an individual determined under subsection
(c) to be an environmental exposure affected individual
described in subsection (e)(2) shall be deemed to meet the
conditions specified in section 226(a).
``(2) Discretionary deeming.--For purposes of eligibility
for benefits under this title, the Secretary may deem an
individual determined under subsection (c) to be an
environmental exposure affected individual described in
subsection (e)(3) to meet the conditions specified in section
226(a).
``(3) Effective date of coverage.--An Individual who is
deemed eligible for benefits under this title under paragraph
(1) or (2) shall be--
``(A) entitled to benefits under the program under Part A
as of the date of such deeming; and
``(B) eligible to enroll in the program under Part B
beginning with the month in which such deeming occurs.
``(b) Pilot Program for Care of Certain Individuals
Residing in Emergency Declaration Areas.--
``(1) Program; purpose.--
``(A) Primary pilot program.--The Secretary shall establish
a pilot program in accordance with this subsection to provide
innovative approaches to furnishing comprehensive,
coordinated, and cost-effective care under this title to
individuals described in paragraph (2)(A).
``(B) Optional pilot programs.--The Secretary may establish
a separate pilot program, in accordance with this subsection,
with respect to each geographic area subject to an emergency
declaration (other than the declaration of June 17, 2009), in
order to furnish such comprehensive, coordinated and cost-
effective care to individuals described in subparagraph
(2)(B) who reside in each such area.
``(2) Individual described.--For purposes of paragraph (1),
an individual described in this paragraph is an individual
who enrolls in part B, submits to the Secretary an
application to participate in the applicable pilot program
under this subsection, and--
``(A) is an environmental exposure affected individual
described in subsection (e)(2) who resides in or around the
geographic area subject to an emergency declaration made as
of June 17, 2009; or
``(B) is an environmental exposure affected individual
described in subsection (e)(3) who--
[[Page H2135]]
``(i) is deemed under subsection (a)(2); and
``(ii) meets such other criteria or conditions for
participation in a pilot program under paragraph (1)(B) as
the Secretary specifies.
``(3) Flexible benefits and services.--A pilot program
under this subsection may provide for the furnishing of
benefits, items, or services not otherwise covered or
authorized under this title, if the Secretary determines that
furnishing such benefits, items, or services will further the
purposes of such pilot program (as described in paragraph
(1)).
``(4) Innovative reimbursement methodologies.--For purposes
of the pilot program under this subsection, the Secretary--
``(A) shall develop and implement appropriate methodologies
to reimburse providers for furnishing benefits, items, or
services for which payment is not otherwise covered or
authorized under this title, if such benefits, items, or
services are furnished pursuant to paragraph (3); and
``(B) may develop and implement innovative approaches to
reimbursing providers for any benefits, items, or services
furnished under this subsection.
``(5) Limitation.--Consistent with section 1862(b), no
payment shall be made under the pilot program under this
subsection with respect to benefits, items, or services
furnished to an environmental exposure affected individual
(as defined in subsection (e)) to the extent that such
individual is eligible to receive such benefits, items, or
services through any other public or private benefits plan or
legal agreement.
``(6) Waiver authority.--The Secretary may waive such
provisions of this title and title XI as are necessary to
carry out pilot programs under this subsection.
``(7) Funding.--For purposes of carrying out pilot programs
under this subsection, the Secretary shall provide for the
transfer, from the Federal Hospital Insurance Trust Fund
under section 1817 and the Federal Supplementary Medical
Insurance Trust Fund under section 1841, in such proportion
as the Secretary determines appropriate, of such sums as the
Secretary determines necessary, to the Centers for Medicare &
Medicaid Services Program Management Account.
``(8) Waiver of budget neutrality.--The Secretary shall not
require that pilot programs under this subsection be budget
neutral with respect to expenditures under this title.
``(c) Determinations.--
``(1) By the commissioner of social security.--For purposes
of this section, the Commissioner of Social Security, in
consultation with the Secretary, and using the cost
allocation method prescribed in section 201(g), shall
determine whether individuals are environmental exposure
affected individuals.
``(2) By the secretary.--The Secretary shall determine
eligibility for pilot programs under subsection (b).
``(d) Emergency Declaration Defined.--For purposes of this
section, the term `emergency declaration' means a declaration
of a public health emergency under section 104(a) of the
Comprehensive Environmental Response, Compensation, and
Liability Act of 1980.
``(e) Environmental Exposure Affected Individual Defined.--
``(1) In general.--For purposes of this section, the term
`environmental exposure affected individual' means--
``(A) an individual described in paragraph (2); and
``(B) an individual described in paragraph (3).
``(2) Individual described.--
``(A) In general.--An individual described in this
paragraph is any individual who--
``(i) is diagnosed with 1 or more conditions described in
subparagraph (B);
``(ii) as demonstrated in such manner as the Secretary
determines appropriate, has been present for an aggregate
total of 6 months in the geographic area subject to an
emergency declaration specified in subsection (b)(2)(A),
during a period ending--
``(I) not less than 10 years prior to such diagnosis; and
``(II) prior to the implementation of all the remedial and
removal actions specified in the Record of Decision for
Operating Unit 4 and the Record of Decision for Operating
Unit 7;
``(iii) files an application for benefits under this title
(or has an application filed on behalf of the individual),
including pursuant to this section; and
``(iv) is determined under this section to meet the
criteria in this subparagraph.
``(B) Conditions described.--For purposes of subparagraph
(A), the following conditions are described in this
subparagraph:
``(i) Asbestosis, pleural thickening, or pleural plaques as
established by--
``(I) interpretation by a `B Reader' qualified physician of
a plain chest x-ray or interpretation of a computed
tomographic radiograph of the chest by a qualified physician,
as determined by the Secretary; or
``(II) such other diagnostic standards as the Secretary
specifies,
except that this clause shall not apply to pleural thickening
or pleural plaques unless there are symptoms or conditions
requiring medical treatment as a result of these diagnoses.
``(ii) Mesothelioma, or malignancies of the lung, colon,
rectum, larynx, stomach, esophagus, pharynx, or ovary, as
established by--
``(I) pathologic examination of biopsy tissue;
``(II) cytology from bronchioalveolar lavage; or
``(III) such other diagnostic standards as the Secretary
specifies.
``(iii) Any other diagnosis which the Secretary, in
consultation with the Commissioner of Social Security,
determines is an asbestos-related medical condition, as
established by such diagnostic standards as the Secretary
specifies.
``(3) Other individual described.--An individual described
in this paragraph is any individual who--
``(A) is not an individual described in paragraph (2);
``(B) is diagnosed with a medical condition caused by the
exposure of the individual to a public health hazard to which
an emergency declaration applies, based on such medical
conditions, diagnostic standards, and other criteria as the
Secretary specifies;
``(C) as demonstrated in such manner as the Secretary
determines appropriate, has been present for an aggregate
total of 6 months in the geographic area subject to the
emergency declaration involved, during a period determined
appropriate by the Secretary;
``(D) files an application for benefits under this title
(or has an application filed on behalf of the individual),
including pursuant to this section; and
``(E) is determined under this section to meet the criteria
in this paragraph.''.
(b) Program for Early Detection of Certain Medical
Conditions Related to Environmental Health Hazards.--Title XX
of the Social Security Act (42 U.S.C. 1397 et seq.), as
amended by section 5507, is amended by adding at the end the
following:
``SEC. 2009. PROGRAM FOR EARLY DETECTION OF CERTAIN MEDICAL
CONDITIONS RELATED TO ENVIRONMENTAL HEALTH
HAZARDS.
``(a) Program Establishment.--The Secretary shall establish
a program in accordance with this section to make competitive
grants to eligible entities specified in subsection (b) for
the purpose of--
``(1) screening at-risk individuals (as defined in
subsection (c)(1)) for environmental health conditions (as
defined in subsection (c)(3)); and
``(2) developing and disseminating public information and
education concerning--
``(A) the availability of screening under the program under
this section;
``(B) the detection, prevention, and treatment of
environmental health conditions; and
``(C) the availability of Medicare benefits for certain
individuals diagnosed with environmental health conditions
under section 1881A.
``(b) Eligible Entities.--
``(1) In general.--For purposes of this section, an
eligible entity is an entity described in paragraph (2) which
submits an application to the Secretary in such form and
manner, and containing such information and assurances, as
the Secretary determines appropriate.
``(2) Types of eligible entities.--The entities described
in this paragraph are the following:
``(A) A hospital or community health center.
``(B) A Federally qualified health center.
``(C) A facility of the Indian Health Service.
``(D) A National Cancer Institute-designated cancer center.
``(E) An agency of any State or local government.
``(F) A nonprofit organization.
``(G) Any other entity the Secretary determines
appropriate.
``(c) Definitions.--In this section:
``(1) At-risk individual.--The term `at-risk individual'
means an individual who--
``(A)(i) as demonstrated in such manner as the Secretary
determines appropriate, has been present for an aggregate
total of 6 months in the geographic area subject to an
emergency declaration specified under paragraph (2), during a
period ending--
``(I) not less than 10 years prior to the date of such
individual's application under subparagraph (B); and
``(II) prior to the implementation of all the remedial and
removal actions specified in the Record of Decision for
Operating Unit 4 and the Record of Decision for Operating
Unit 7; or
``(ii) meets such other criteria as the Secretary
determines appropriate considering the type of environmental
health condition at issue; and
``(B) has submitted an application (or has an application
submitted on the individual's behalf), to an eligible entity
receiving a grant under this section, for screening under the
program under this section.
``(2) Emergency declaration.--The term `emergency
declaration' means a declaration of a public health emergency
under section 104(a) of the Comprehensive Environmental
Response, Compensation, and Liability Act of 1980.
``(3) Environmental health condition.--The term
`environmental health condition' means--
``(A) asbestosis, pleural thickening, or pleural plaques,
as established by--
``(i) interpretation by a `B Reader' qualified physician of
a plain chest x-ray or interpretation of a computed
tomographic radiograph of the chest by a qualified physician,
as determined by the Secretary; or
``(ii) such other diagnostic standards as the Secretary
specifies;
``(B) mesothelioma, or malignancies of the lung, colon,
rectum, larynx, stomach, esophagus, pharynx, or ovary, as
established by--
``(i) pathologic examination of biopsy tissue;
``(ii) cytology from bronchioalveolar lavage; or
``(iii) such other diagnostic standards as the Secretary
specifies; and
``(C) any other medical condition which the Secretary
determines is caused by exposure to a hazardous substance or
pollutant or contaminant at a Superfund site to which an
emergency declaration applies, based on such criteria and as
established by such diagnostic standards as the Secretary
specifies.
``(4) Hazardous substance; pollutant; contaminant.--The
terms `hazardous substance', `pollutant', and `contaminant'
have the meanings given those terms in section 101 of the
Comprehensive Environmental Response, Compensation, and
Liability Act of 1980 (42 U.S.C. 9601).
[[Page H2136]]
``(5) Superfund site.--The term `Superfund site' means a
site included on the National Priorities List developed by
the President in accordance with section 105(a)(8)(B) of the
Comprehensive Environmental Response, Compensation, and
Liability Act of 1980 (42 U.S.C. 9605(a)(8)(B)).
``(d) Health Coverage Unaffected.--Nothing in this section
shall be construed to affect any coverage obligation of a
governmental or private health plan or program relating to an
at-risk individual.
``(e) Funding.--
``(1) In general.--Out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the
Secretary, to carry out the program under this section--
``(A) $23,000,000 for the period of fiscal years 2010
through 2014; and
``(B) $20,000,000 for each 5-fiscal year period thereafter.
``(2) Availability.--Funds appropriated under paragraph (1)
shall remain available until expended.
``(f) Nonapplication.--
``(1) In general.--Except as provided in paragraph (2), the
preceding sections of this title shall not apply to grants
awarded under this section.
``(2) Limitations on use of grants.--Section 2005(a) shall
apply to a grant awarded under this section to the same
extent and in the same manner as such section applies to
payments to States under this title, except that paragraph
(4) of such section shall not be construed to prohibit
grantees from conducting screening for environmental health
conditions as authorized under this section.''.
SEC. 10324. PROTECTIONS FOR FRONTIER STATES.
(a) Floor on Area Wage Index for Hospitals in Frontier
States.--
(1) In general.--Section 1886(d)(3)(E) of the Social
Security Act (42 U.S.C. 1395ww(d)(3)(E)) is amended--
(A) in clause (i), by striking ``clause (ii)'' and
inserting ``clause (ii) or (iii)''; and
(B) by adding at the end the following new clause:
``(iii) Floor on area wage index for hospitals in frontier
states.--
``(I) In general.--Subject to subclause (IV), for
discharges occurring on or after October 1, 2010, the area
wage index applicable under this subparagraph to any hospital
which is located in a frontier State (as defined in subclause
(II)) may not be less than 1.00.
``(II) Frontier state defined.--In this clause, the term
`frontier State' means a State in which at least 50 percent
of the counties in the State are frontier counties.
``(III) Frontier county defined.--In this clause, the term
`frontier county' means a county in which the population per
square mile is less than 6.
``(IV) Limitation.--This clause shall not apply to any
hospital located in a State that receives a non-labor related
share adjustment under paragraph (5)(H).''.
(2) Waiving budget neutrality.--Section 1886(d)(3)(E) of
the Social Security Act (42 U.S.C. 1395ww(d)(3)(E)), as
amended by subsection (a), is amended in the third sentence
by inserting ``and the amendments made by section 10324(a)(1)
of the Patient Protection and Affordable Care Act'' after
``2003''.
(b) Floor on Area Wage Adjustment Factor for Hospital
Outpatient Department Services in Frontier States.--Section
1833(t) of the Social Security Act (42 U.S.C. 1395l(t)), as
amended by section 3138, is amended--
(1) in paragraph (2)(D), by striking ``the Secretary'' and
inserting ``subject to paragraph (19), the Secretary''; and
(2) by adding at the end the following new paragraph:
``(19) Floor on area wage adjustment factor for hospital
outpatient department services in frontier states.--
``(A) In general.--Subject to subparagraph (B), with
respect to covered OPD services furnished on or after January
1, 2011, the area wage adjustment factor applicable under the
payment system established under this subsection to any
hospital outpatient department which is located in a frontier
State (as defined in section 1886(d)(3)(E)(iii)(II)) may not
be less than 1.00. The preceding sentence shall not be
applied in a budget neutral manner.
``(B) Limitation.--This paragraph shall not apply to any
hospital outpatient department located in a State that
receives a non-labor related share adjustment under section
1886(d)(5)(H).''.
(c) Floor for Practice Expense Index for Physicians'
Services Furnished in Frontier States.--Section 1848(e)(1) of
the Social Security Act (42 U.S.C. 1395w-4(e)(1)), as amended
by section 3102, is amended--
(1) in subparagraph (A), by striking ``and (H)'' and
inserting ``(H), and (I)''; and
(2) by adding at the end the following new subparagraph:
``(I) Floor for practice expense index for services
furnished in frontier states.--
``(i) In general.--Subject to clause (ii), for purposes of
payment for services furnished in a frontier State (as
defined in section 1886(d)(3)(E)(iii)(II)) on or after
January 1, 2011, after calculating the practice expense index
in subparagraph (A)(i), the Secretary shall increase any such
index to 1.00 if such index would otherwise be less that
1.00. The preceding sentence shall not be applied in a budget
neutral manner.
``(ii) Limitation.--This subparagraph shall not apply to
services furnished in a State that receives a non-labor
related share adjustment under section 1886(d)(5)(H).''.
SEC. 10325. REVISION TO SKILLED NURSING FACILITY PROSPECTIVE
PAYMENT SYSTEM.
(a) Temporary Delay of RUG-IV.--Notwithstanding any other
provision of law, the Secretary of Health and Human Services
shall not, prior to October 1, 2011, implement Version 4 of
the Resource Utilization Groups (in this subsection refereed
to as ``RUG-IV'') published in the Federal Register on August
11, 2009, entitled ``Prospective Payment System and
Consolidated Billing for Skilled Nursing Facilities for FY
2010; Minimum Data Set, Version 3.0 for Skilled Nursing
Facilities and Medicaid Nursing Facilities'' (74 Fed. Reg.
40288). Beginning on October 1, 2010, the Secretary of Health
and Human Services shall implement the change specific to
therapy furnished on a concurrent basis that is a component
of RUG-IV and changes to the lookback period to ensure that
only those services furnished after admission to a skilled
nursing facility are used as factors in determining a case
mix classification under the skilled nursing facility
prospective payment system under section 1888(e) of the
Social Security Act (42 U.S.C. 1395yy(e)).
(b) Construction.--Nothing in this section shall be
interpreted as delaying the implementation of Version 3.0 of
the Minimum Data Sets (MDS 3.0) beyond the planned
implementation date of October 1, 2010.
SEC. 10326. PILOT TESTING PAY-FOR-PERFORMANCE PROGRAMS FOR
CERTAIN MEDICARE PROVIDERS.
(a) In General.--Not later than January 1, 2016, the
Secretary of Health and Human Services (in this section
referred to as the ``Secretary'') shall, for each provider
described in subsection (b), conduct a separate pilot program
under title XVIII of the Social Security Act to test the
implementation of a value-based purchasing program for
payments under such title for the provider.
(b) Providers Described.--The providers described in this
paragraph are the following:
(1) Psychiatric hospitals (as described in clause (i) of
section 1886(d)(1)(B) of such Act (42 U.S.C.
1395ww(d)(1)(B))) and psychiatric units (as described in the
matter following clause (v) of such section).
(2) Long-term care hospitals (as described in clause (iv)
of such section).
(3) Rehabilitation hospitals (as described in clause (ii)
of such section).
(4) PPS-exempt cancer hospitals (as described in clause (v)
of such section).
(5) Hospice programs (as defined in section 1861(dd)(2) of
such Act (42 U.S.C. 1395x(dd)(2))).
(c) Waiver Authority.--The Secretary may waive such
requirements of titles XI and XVIII of the Social Security
Act as may be necessary solely for purposes of carrying out
the pilot programs under this section.
(d) No Additional Program Expenditures.--Payments under
this section under the separate pilot program for value based
purchasing (as described in subsection (a)) for each provider
type described in paragraphs (1) through (5) of subsection
(b) for applicable items and services under title XVIII of
the Social Security Act for a year shall be established in a
manner that does not result in spending more under each such
value based purchasing program for such year than would
otherwise be expended for such provider type for such year if
the pilot program were not implemented, as estimated by the
Secretary.
(e) Expansion of Pilot Program.--The Secretary may, at any
point after January 1, 2018, expand the duration and scope of
a pilot program conducted under this subsection, to the
extent determined appropriate by the Secretary, if--
(1) the Secretary determines that such expansion is
expected to--
(A) reduce spending under title XVIII of the Social
Security Act without reducing the quality of care; or
(B) improve the quality of care and reduce spending;
(2) the Chief Actuary of the Centers for Medicare &
Medicaid Services certifies that such expansion would reduce
program spending under such title XVIII; and
(3) the Secretary determines that such expansion would not
deny or limit the coverage or provision of benefits under
such title XIII for Medicare beneficiaries.
SEC. 10327. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING
SYSTEM.
(a) In General.--Section 1848(m) of the Social Security Act
(42 U.S.C. 1395w-4(m)) is amended by adding at the end the
following new paragraph:
``(7) Additional incentive payment.--
``(A) In general.--For 2011 through 2014, if an eligible
professional meets the requirements described in subparagraph
(B), the applicable quality percent for such year, as
described in clauses (iii) and (iv) of paragraph (1)(B),
shall be increased by 0.5 percentage points.
``(B) Requirements described.--In order to qualify for the
additional incentive payment described in subparagraph (A),
an eligible professional shall meet the following
requirements:
``(i) The eligible professional shall--
``(I) satisfactorily submit data on quality measures for
purposes of paragraph (1) for a year; and
``(II) have such data submitted on their behalf through a
Maintenance of Certification Program (as defined in
subparagraph (C)(i)) that meets--
``(aa) the criteria for a registry (as described in
subsection (k)(4)); or
``(bb) an alternative form and manner determined
appropriate by the Secretary.
``(ii) The eligible professional, more frequently than is
required to qualify for or maintain board certification
status--
``(I) participates in such a Maintenance of Certification
program for a year; and
``(II) successfully completes a qualified Maintenance of
Certification Program practice assessment (as defined in
subparagraph (C)(ii)) for such year.
[[Page H2137]]
``(iii) A Maintenance of Certification program submits to
the Secretary, on behalf of the eligible professional,
information--
``(I) in a form and manner specified by the Secretary, that
the eligible professional has successfully met the
requirements of clause (ii) (which may be in the form of a
structural measure);
``(II) if requested by the Secretary, on the survey of
patient experience with care (as described in subparagraph
(C)(ii)(II)); and
``(III) as the Secretary may require, on the methods,
measures, and data used under the Maintenance of
Certification Program and the qualified Maintenance of
Certification Program practice assessment.
``(C) Definitions.--For purposes of this paragraph:
``(i) The term `Maintenance of Certification Program' means
a continuous assessment program, such as qualified American
Board of Medical Specialties Maintenance of Certification
program or an equivalent program (as determined by the
Secretary), that advances quality and the lifelong learning
and self-assessment of board certified specialty physicians
by focusing on the competencies of patient care, medical
knowledge, practice-based learning, interpersonal and
communication skills and professionalism. Such a program
shall include the following:
``(I) The program requires the physician to maintain a
valid, unrestricted medical license in the United States.
``(II) The program requires a physician to participate in
educational and self-assessment programs that require an
assessment of what was learned.
``(III) The program requires a physician to demonstrate,
through a formalized, secure examination, that the physician
has the fundamental diagnostic skills, medical knowledge, and
clinical judgment to provide quality care in their respective
specialty.
``(IV) The program requires successful completion of a
qualified Maintenance of Certification Program practice
assessment as described in clause (ii).
``(ii) The term `qualified Maintenance of Certification
Program practice assessment' means an assessment of a
physician's practice that--
``(I) includes an initial assessment of an eligible
professional's practice that is designed to demonstrate the
physician's use of evidence-based medicine;
``(II) includes a survey of patient experience with care;
and
``(III) requires a physician to implement a quality
improvement intervention to address a practice weakness
identified in the initial assessment under subclause (I) and
then to remeasure to assess performance improvement after
such intervention.''.
(b) Authority.--Section 3002(c) of this Act is amended by
adding at the end the following new paragraph:
``(3) Authority.--For years after 2014, if the Secretary of
Health and Human Services determines it to be appropriate,
the Secretary may incorporate participation in a Maintenance
of Certification Program and successful completion of a
qualified Maintenance of Certification Program practice
assessment into the composite of measures of quality of care
furnished pursuant to the physician fee schedule payment
modifier, as described in section 1848(p)(2) of the Social
Security Act (42 U.S.C. 1395w-4(p)(2)).''.
(c) Elimination of MA Regional Plan Stabilization Fund.--
(1) In general.--Section 1858 of the Social Security Act
(42 U.S.C. 1395w-27a) is amended by striking subsection (e).
(2) Transition.--Any amount contained in the MA Regional
Plan Stabilization Fund as of the date of the enactment of
this Act shall be transferred to the Federal Supplementary
Medical Insurance Trust Fund.
SEC. 10328. IMPROVEMENT IN PART D MEDICATION THERAPY
MANAGEMENT (MTM) PROGRAMS.
(a) In General.--Section 1860D-4(c)(2) of the Social
Security Act (42 U.S.C. 1395w-104(c)(2)) is amended--
(1) by redesignating subparagraphs (C), (D), and (E) as
subparagraphs (E), (F), and (G), respectively; and
(2) by inserting after subparagraph (B) the following new
subparagraphs:
``(C) Required interventions.--For plan years beginning on
or after the date that is 2 years after the date of the
enactment of the Patient Protection and Affordable Care Act,
prescription drug plan sponsors shall offer medication
therapy management services to targeted beneficiaries
described in subparagraph (A)(ii) that include, at a minimum,
the following to increase adherence to prescription
medications or other goals deemed necessary by the Secretary:
``(i) An annual comprehensive medication review furnished
person-to-person or using telehealth technologies (as defined
by the Secretary) by a licensed pharmacist or other qualified
provider. The comprehensive medication review--
``(I) shall include a review of the individual's
medications and may result in the creation of a recommended
medication action plan or other actions in consultation with
the individual and with input from the prescriber to the
extent necessary and practicable; and
``(II) shall include providing the individual with a
written or printed summary of the results of the review.
The Secretary, in consultation with relevant stakeholders,
shall develop a standardized format for the action plan under
subclause (I) and the summary under subclause (II).
``(ii) Follow-up interventions as warranted based on the
findings of the annual medication review or the targeted
medication enrollment and which may be provided person-to-
person or using telehealth technologies (as defined by the
Secretary).
``(D) Assessment.--The prescription drug plan sponsor shall
have in place a process to assess, at least on a quarterly
basis, the medication use of individuals who are at risk but
not enrolled in the medication therapy management program,
including individuals who have experienced a transition in
care, if the prescription drug plan sponsor has access to
that information.
``(E) Automatic enrollment with ability to opt-out.--The
prescription drug plan sponsor shall have in place a process
to--
``(i) subject to clause (ii), automatically enroll targeted
beneficiaries described in subparagraph (A)(ii), including
beneficiaries identified under subparagraph (D), in the
medication therapy management program required under this
subsection; and
``(ii) permit such beneficiaries to opt-out of enrollment
in such program.''.
(b) Rule of Construction.--Nothing in this section shall
limit the authority of the Secretary of Health and Human
Services to modify or broaden requirements for a medication
therapy management program under part D of title XVIII of the
Social Security Act or to study new models for medication
therapy management through the Center for Medicare and
Medicaid Innovation under section 1115A of such Act, as added
by section 3021.
SEC. 10329. DEVELOPING METHODOLOGY TO ASSESS HEALTH PLAN
VALUE.
(a) Development.--The Secretary of Health and Human
Services (referred to in this section as the ``Secretary''),
in consultation with relevant stakeholders including health
insurance issuers, health care consumers, employers, health
care providers, and other entities determined appropriate by
the Secretary, shall develop a methodology to measure health
plan value. Such methodology shall take into consideration,
where applicable--
(1) the overall cost to enrollees under the plan;
(2) the quality of the care provided for under the plan;
(3) the efficiency of the plan in providing care;
(4) the relative risk of the plan's enrollees as compared
to other plans;
(5) the actuarial value or other comparative measure of the
benefits covered under the plan; and
(6) other factors determined relevant by the Secretary.
(b) Report.--Not later than 18 months after the date of
enactment of this Act, the Secretary shall submit to Congress
a report concerning the methodology developed under
subsection (a).
SEC. 10330. MODERNIZING COMPUTER AND DATA SYSTEMS OF THE
CENTERS FOR MEDICARE & MEDICAID SERVICES TO
SUPPORT IMPROVEMENTS IN CARE DELIVERY.
(a) In General.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
develop a plan (and detailed budget for the resources needed
to implement such plan) to modernize the computer and data
systems of the Centers for Medicare & Medicaid Services (in
this section referred to as ``CMS'').
(b) Considerations.--In developing the plan, the Secretary
shall consider how such modernized computer system could--
(1) in accordance with the regulations promulgated under
section 264(c) of the Health Insurance Portability and
Accountability Act of 1996, make available data in a reliable
and timely manner to providers of services and suppliers to
support their efforts to better manage and coordinate care
furnished to beneficiaries of CMS programs; and
(2) support consistent evaluations of payment and delivery
system reforms under CMS programs.
(c) Posting of Plan.--By not later than 9 months after the
date of the enactment of this Act, the Secretary shall post
on the website of the Centers for Medicare & Medicaid
Services the plan described in subsection (a).
SEC. 10331. PUBLIC REPORTING OF PERFORMANCE INFORMATION.
(a) In General.--
(1) Development.--Not later than January 1, 2011, the
Secretary shall develop a Physician Compare Internet website
with information on physicians enrolled in the Medicare
program under section 1866(j) of the Social Security Act (42
U.S.C. 1395cc(j)) and other eligible professionals who
participate in the Physician Quality Reporting Initiative
under section 1848 of such Act (42 U.S.C. 1395w-4).
(2) Plan.--Not later than January 1, 2013, and with respect
to reporting periods that begin no earlier than January 1,
2012, the Secretary shall also implement a plan for making
publicly available through Physician Compare, consistent with
subsection (c), information on physician performance that
provides comparable information for the public on quality and
patient experience measures with respect to physicians
enrolled in the Medicare program under such section 1866(j).
To the extent scientifically sound measures that are
developed consistent with the requirements of this section
are available, such information, to the extent practicable,
shall include--
(A) measures collected under the Physician Quality
Reporting Initiative;
(B) an assessment of patient health outcomes and the
functional status of patients;
(C) an assessment of the continuity and coordination of
care and care transitions, including episodes of care and
risk-adjusted resource use;
(D) an assessment of efficiency;
(E) an assessment of patient experience and patient,
caregiver, and family engagement;
(F) an assessment of the safety, effectiveness, and
timeliness of care; and
[[Page H2138]]
(G) other information as determined appropriate by the
Secretary.
(b) Other Required Considerations.--In developing and
implementing the plan described in subsection (a)(2), the
Secretary shall, to the extent practicable, include--
(1) processes to assure that data made public, either by
the Centers for Medicare & Medicaid Services or by other
entities, is statistically valid and reliable, including risk
adjustment mechanisms used by the Secretary;
(2) processes by which a physician or other eligible
professional whose performance on measures is being publicly
reported has a reasonable opportunity, as determined by the
Secretary, to review his or her individual results before
they are made public;
(3) processes by the Secretary to assure that the
implementation of the plan and the data made available on
Physician Compare provide a robust and accurate portrayal of
a physician's performance;
(4) data that reflects the care provided to all patients
seen by physicians, under both the Medicare program and, to
the extent practicable, other payers, to the extent such
information would provide a more accurate portrayal of
physician performance;
(5) processes to ensure appropriate attribution of care
when multiple physicians and other providers are involved in
the care of a patient;
(6) processes to ensure timely statistical performance
feedback is provided to physicians concerning the data
reported under any program subject to public reporting under
this section; and
(7) implementation of computer and data systems of the
Centers for Medicare & Medicaid Services that support valid,
reliable, and accurate public reporting activities authorized
under this section.
(c) Ensuring Patient Privacy.--The Secretary shall ensure
that information on physician performance and patient
experience is not disclosed under this section in a manner
that violates sections 552 or 552a of title 5, United States
Code, with regard to the privacy of individually identifiable
health information.
(d) Feedback From Multi-stakeholder Groups.--The Secretary
shall take into consideration input provided by multi-
stakeholder groups, consistent with sections 1890(b)(7) and
1890A of the Social Security Act, as added by section 3014 of
this Act, in selecting quality measures for use under this
section.
(e) Consideration of Transition to Value-based
Purchasing.--In developing the plan under this subsection
(a)(2), the Secretary shall, as the Secretary determines
appropriate, consider the plan to transition to a value-based
purchasing program for physicians and other practitioners
developed under section 131 of the Medicare Improvements for
Patients and Providers Act of 2008 (Public Law 110-275).
(f) Report to Congress.--Not later than January 1, 2015,
the Secretary shall submit to Congress a report on the
Physician Compare Internet website developed under subsection
(a)(1). Such report shall include information on the efforts
of and plans made by the Secretary to collect and publish
data on physician quality and efficiency and on patient
experience of care in support of value-based purchasing and
consumer choice, together with recommendations for such
legislation and administrative action as the Secretary
determines appropriate.
(g) Expansion.--At any time before the date on which the
report is submitted under subsection (f), the Secretary may
expand (including expansion to other providers of services
and suppliers under title XVIII of the Social Security Act)
the information made available on such website.
(h) Financial Incentives To Encourage Consumers To Choose
High Quality Providers.--The Secretary may establish a
demonstration program, not later than January 1, 2019, to
provide financial incentives to Medicare beneficiaries who
are furnished services by high quality physicians, as
determined by the Secretary based on factors in subparagraphs
(A) through (G) of subsection (a)(2). In no case may Medicare
beneficiaries be required to pay increased premiums or cost
sharing or be subject to a reduction in benefits under title
XVIII of the Social Security Act as a result of such
demonstration program. The Secretary shall ensure that any
such demonstration program does not disadvantage those
beneficiaries without reasonable access to high performing
physicians or create financial inequities under such title.
(i) Definitions.--In this section:
(1) Eligible professional.--The term ``eligible
professional'' has the meaning given that term for purposes
of the Physician Quality Reporting Initiative under section
1848 of the Social Security Act (42 U.S.C. 1395w-4).
(2) Physician.--The term ``physician'' has the meaning
given that term in section 1861(r) of such Act (42 U.S.C.
1395x(r)).
(3) Physician compare.--The term ``Physician Compare''
means the Internet website developed under subsection (a)(1).
(4) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
SEC. 10332. AVAILABILITY OF MEDICARE DATA FOR PERFORMANCE
MEASUREMENT.
(a) In General.--Section 1874 of the Social Security Act
(42 U.S.C. 1395kk) is amended by adding at the end the
following new subsection:
``(e) Availability of Medicare Data.--
``(1) In general.--Subject to paragraph (4), the Secretary
shall make available to qualified entities (as defined in
paragraph (2)) data described in paragraph (3) for the
evaluation of the performance of providers of services and
suppliers.
``(2) Qualified entities.--For purposes of this subsection,
the term `qualified entity' means a public or private entity
that--
``(A) is qualified (as determined by the Secretary) to use
claims data to evaluate the performance of providers of
services and suppliers on measures of quality, efficiency,
effectiveness, and resource use; and
``(B) agrees to meet the requirements described in
paragraph (4) and meets such other requirements as the
Secretary may specify, such as ensuring security of data.
``(3) Data described.--The data described in this paragraph
are standardized extracts (as determined by the Secretary) of
claims data under parts A, B, and D for items and services
furnished under such parts for one or more specified
geographic areas and time periods requested by a qualified
entity. The Secretary shall take such actions as the
Secretary deems necessary to protect the identity of
individuals entitled to or enrolled for benefits under such
parts.
``(4) Requirements.--
``(A) Fee.--Data described in paragraph (3) shall be made
available to a qualified entity under this subsection at a
fee equal to the cost of making such data available. Any fee
collected pursuant to the preceding sentence shall be
deposited into the Federal Supplementary Medical Insurance
Trust Fund under section 1841.
``(B) Specification of uses and methodologies.--A qualified
entity requesting data under this subsection shall--
``(i) submit to the Secretary a description of the
methodologies that such qualified entity will use to evaluate
the performance of providers of services and suppliers using
such data;
``(ii)(I) except as provided in subclause (II), if
available, use standard measures, such as measures endorsed
by the entity with a contract under section 1890(a) and
measures developed pursuant to section 931 of the Public
Health Service Act; or
``(II) use alternative measures if the Secretary, in
consultation with appropriate stakeholders, determines that
use of such alternative measures would be more valid,
reliable, responsive to consumer preferences, cost-effective,
or relevant to dimensions of quality and resource use not
addressed by such standard measures;
``(iii) include data made available under this subsection
with claims data from sources other than claims data under
this title in the evaluation of performance of providers of
services and suppliers;
``(iv) only include information on the evaluation of
performance of providers and suppliers in reports described
in subparagraph (C);
``(v) make available to providers of services and
suppliers, upon their request, data made available under this
subsection; and
``(vi) prior to their release, submit to the Secretary the
format of reports under subparagraph (C).
``(C) Reports.--Any report by a qualified entity evaluating
the performance of providers of services and suppliers using
data made available under this subsection shall--
``(i) include an understandable description of the
measures, which shall include quality measures and the
rationale for use of other measures described in subparagraph
(B)(ii)(II), risk adjustment methods, physician attribution
methods, other applicable methods, data specifications and
limitations, and the sponsors, so that consumers, providers
of services and suppliers, health plans, researchers, and
other stakeholders can assess such reports;
``(ii) be made available confidentially, to any provider of
services or supplier to be identified in such report, prior
to the public release of such report, and provide an
opportunity to appeal and correct errors;
``(iii) only include information on a provider of services
or supplier in an aggregate form as determined appropriate by
the Secretary; and
``(iv) except as described in clause (ii), be made
available to the public.
``(D) Approval and limitation of uses.--The Secretary shall
not make data described in paragraph (3) available to a
qualified entity unless the qualified entity agrees to
release the information on the evaluation of performance of
providers of services and suppliers. Such entity shall only
use such data, and information derived from such evaluation,
for the reports under subparagraph (C). Data released to a
qualified entity under this subsection shall not be subject
to discovery or admission as evidence in judicial or
administrative proceedings without consent of the applicable
provider of services or supplier.''.
(b) Effective Date.--The amendment made by subsection (a)
shall take effect on January 1, 2012.
SEC. 10333. COMMUNITY-BASED COLLABORATIVE CARE NETWORKS.
Part D of title III of the Public Health Service Act (42
U.S.C. 254b et seq.) is amended by adding at the end the
following new subpart:
``Subpart XI--Community-Based Collaborative Care Network Program
``SEC. 340H. COMMUNITY-BASED COLLABORATIVE CARE NETWORK
PROGRAM.
``(a) In General.--The Secretary may award grants to
eligible entities to support community-based collaborative
care networks that meet the requirements of subsection (b).
``(b) Community-based Collaborative Care Networks.--
``(1) Description.--A community-based collaborative care
network (referred to in this section as a `network') shall be
a consortium of health care providers with a joint governance
structure (including providers within a single entity) that
provides comprehensive coordinated and integrated health care
services (as defined by the Secretary) for low-income
populations.
``(2) Required inclusion.--A network shall include the
following providers (unless such provider does not exist
within the community, declines or refuses to participate, or
places unreasonable conditions on their participation):
``(A) A hospital that meets the criteria in section
1923(b)(1) of the Social Security Act; and
``(B) All Federally qualified health centers (as defined in
section 1861(aa) of the Social Security Act located in the
community.
[[Page H2139]]
``(3) Priority.--In awarding grants, the Secretary shall
give priority to networks that include--
``(A) the capability to provide the broadest range of
services to low-income individuals;
``(B) the broadest range of providers that currently serve
a high volume of low-income individuals; and
``(C) a county or municipal department of health.
``(c) Application.--
``(1) Application.--A network described in subsection (b)
shall submit an application to the Secretary.
``(2) Renewal.--In subsequent years, based on the
performance of grantees, the Secretary may provide renewal
grants to prior year grant recipients.
``(d) Use of Funds.--
``(1) Use by grantees.--Grant funds may be used for the
following activities:
``(A) Assist low-income individuals to--
``(i) access and appropriately use health services;
``(ii) enroll in health coverage programs; and
``(iii) obtain a regular primary care provider or a medical
home.
``(B) Provide case management and care management.
``(C) Perform health outreach using neighborhood health
workers or through other means.
``(D) Provide transportation.
``(E) Expand capacity, including through telehealth, after-
hours services or urgent care.
``(F) Provide direct patient care services.
``(2) Grant funds to hrsa grantees.--The Secretary may
limit the percent of grant funding that may be spent on
direct care services provided by grantees of programs
administered by the Health Resources and Services
Administration or impose other requirements on such grantees
deemed necessary.
``(e) Authorization of Appropriations.--There are
authorized to be appropriated to carry out this section such
sums as may be necessary for each of fiscal years 2011
through 2015.''.
SEC. 10334. MINORITY HEALTH.
(a) Office of Minority Health.--
(1) In general.--Section 1707 of the Public Health Service
Act (42 U.S.C. 300u-6) is amended--
(A) in subsection (a), by striking ``within the Office of
Public Health and Science'' and all that follows through the
end and inserting ``. The Office of Minority Health as
existing on the date of enactment of the Patient Protection
and Affordable Care Act shall be transferred to the Office of
the Secretary in such manner that there is established in the
Office of the Secretary, the Office of Minority Health, which
shall be headed by the Deputy Assistant Secretary for
Minority Health who shall report directly to the Secretary,
and shall retain and strengthen authorities (as in existence
on such date of enactment) for the purpose of improving
minority health and the quality of health care minorities
receive, and eliminating racial and ethnic disparities. In
carrying out this subsection, the Secretary, acting through
the Deputy Assistant Secretary, shall award grants,
contracts, enter into memoranda of understanding,
cooperative, interagency, intra-agency and other agreements
with public and nonprofit private entities, agencies, as well
as Departmental and Cabinet agencies and organizations, and
with organizations that are indigenous human resource
providers in communities of color to assure improved health
status of racial and ethnic minorities, and shall develop
measures to evaluate the effectiveness of activities aimed at
reducing health disparities and supporting the local
community. Such measures shall evaluate community outreach
activities, language services, workforce cultural competence,
and other areas as determined by the Secretary.''; and
(B) by striking subsection (h) and inserting the following:
``(h) Authorization of Appropriations.--For the purpose of
carrying out this section, there are authorized to be
appropriated such sums as may be necessary for each of fiscal
years 2011 through 2016.''.
(2) Transfer of functions.--There are transferred to the
Office of Minority Health in the office of the Secretary of
Health and Human Services, all duties, responsibilities,
authorities, accountabilities, functions, staff, funds, award
mechanisms, and other entities under the authority of the
Office of Minority Health of the Public Health Service as in
effect on the date before the date of enactment of this Act,
which shall continue in effect according to the terms in
effect on the date before such date of enactment, until
modified, terminated, superseded, set aside, or revoked in
accordance with law by the President, the Secretary, a court
of competent jurisdiction, or by operation of law.
(3) Reports.--Not later than 1 year after the date of
enactment of this section, and biennially thereafter, the
Secretary of Health and Human Services shall prepare and
submit to the appropriate committees of Congress a report
describing the activities carried out under section 1707 of
the Public Health Service Act (as amended by this subsection)
during the period for which the report is being prepared. Not
later than 1 year after the date of enactment of this
section, and biennially thereafter, the heads of each of the
agencies of the Department of Health and Human Services shall
submit to the Deputy Assistant Secretary for Minority Health
a report summarizing the minority health activities of each
of the respective agencies.
(b) Establishment of Individual Offices of Minority Health
Within the Department of Health and Human Services.--
(1) In general.--Title XVII of the Public Health Service
Act (42 U.S.C. 300u et seq.) is amended by inserting after
section 1707 the following section:
``SEC. 1707A. INDIVIDUAL OFFICES OF MINORITY HEALTH WITHIN
THE DEPARTMENT.
``(a) In General.--The head of each agency specified in
subsection (b)(1) shall establish within the agency an office
to be known as the Office of Minority Health. The head of
each such Office shall be appointed by the head of the agency
within which the Office is established, and shall report
directly to the head of the agency. The head of such agency
shall carry out this section (as this section relates to the
agency) acting through such Director.
``(b) Specified Agencies.--The agencies referred to in
subsection (a) are the Centers for Disease Control and
Prevention, the Health Resources and Services Administration,
the Substance Abuse and Mental Health Services
Administration, the Agency for Healthcare Research and
Quality, the Food and Drug Administration, and the Centers
for Medicare & Medicaid Services.
``(c) Director; Appointment.--Each Office of Minority
Health established in an agency listed in subsection (a)
shall be headed by a director, with documented experience and
expertise in minority health services research and health
disparities elimination.
``(d) References.--Except as otherwise specified, any
reference in Federal law to an Office of Minority Health (in
the Department of Health and Human Services) is deemed to be
a reference to the Office of Minority Health in the Office of
the Secretary.
``(e) Funding.--
``(1) Allocations.--Of the amounts appropriated for a
specified agency for a fiscal year, the Secretary must
designate an appropriate amount of funds for the purpose of
carrying out activities under this section through the
minority health office of the agency. In reserving an amount
under the preceding sentence for a minority health office for
a fiscal year, the Secretary shall reduce, by substantially
the same percentage, the amount that otherwise would be
available for each of the programs of the designated agency
involved.
``(2) Availability of funds for staffing.--The purposes for
which amounts made available under paragraph may be expended
by a minority health office include the costs of employing
staff for such office.''.
(2) No new regulatory authority.--Nothing in this
subsection and the amendments made by this subsection may be
construed as establishing regulatory authority or modifying
any existing regulatory authority.
(3) Limitation on termination.--Notwithstanding any other
provision of law, a Federal office of minority health or
Federal appointive position with primary responsibility over
minority health issues that is in existence in an office of
agency of the Department of Health and Human Services on the
date of enactment of this section shall not be terminated,
reorganized, or have any of its power or duties transferred
unless such termination, reorganization, or transfer is
approved by an Act of Congress.
(c) Redesignation of National Center on Minority Health and
Health Disparities.--
(1) Redesignation.--Title IV of the Public Health Service
Act (42 U.S.C. 281 et seq.) is amended--
(A) by redesignating subpart 6 of part E as subpart 20;
(B) by transferring subpart 20, as so redesignated, to part
C of such title IV;
(C) by inserting subpart 20, as so redesignated, after
subpart 19 of such part C; and
(D) in subpart 20, as so redesignated--
(i) by redesignating sections 485E through 485H as sections
464z-3 through 464z-6, respectively;
(ii) by striking ``National Center on Minority Health and
Health Disparities'' each place such term appears and
inserting ``National Institute on Minority Health and Health
Disparities''; and
(iii) by striking ``Center'' each place such term appears
and inserting ``Institute''.
(2) Purpose of institute; duties.--Section 464z-3 of the
Public Health Service Act, as so redesignated, is amended--
(A) in subsection (h)(1), by striking ``research endowments
at centers of excellence under section 736.'' and inserting
the following: ``research endowments--
``(1) at centers of excellence under section 736; and
``(2) at centers of excellence under section 464z-4.'';
(B) in subsection (h)(2)(A), by striking ``average'' and
inserting ``median''; and
(C) by adding at the end the following:
``(h) Interagency Coordination.--The Director of the
Institute, as the primary Federal officials with
responsibility for coordinating all research and activities
conducted or supported by the National Institutes of Health
on minority health and health disparities, shall plan,
coordinate, review and evaluate research and other activities
conducted or supported by the Institutes and Centers of the
National Institutes of Health.''.
(3) Technical and conforming amendments.--
(A) Section 401(b)(24) of the Public Health Service Act (42
U.S.C. 281(b)(24)) is amended by striking ``Center'' and
inserting ``Institute''.
(B) Subsection (d)(1) of section 903 of the Public Health
Service Act (42 U.S.C. 299a-1(d)(1)) is amended by striking
``section 485E'' and inserting ``section 464z-3''.
SEC. 10335. TECHNICAL CORRECTION TO THE HOSPITAL VALUE-BASED
PURCHASING PROGRAM.
Section 1886(o)(2)A) of the Social Security Act, as added
by section 3001, is amended, in the first sentence, by
inserting ``, other than measures of readmissions,'' after
``shall select measures''.
SEC. 10336. GAO STUDY AND REPORT ON MEDICARE BENEFICIARY
ACCESS TO HIGH-QUALITY DIALYSIS SERVICES.
(a) Study.--
(1) In general.--The Comptroller General of the United
States shall conduct a study on the
[[Page H2140]]
impact on Medicare beneficiary access to high-quality
dialysis services of including specified oral drugs that are
furnished to such beneficiaries for the treatment of end
stage renal disease in the bundled prospective payment system
under section 1881(b)(14) of the Social Security Act (42
U.S.C. 1395rr(b)(14)) (pursuant to the proposed rule
published by the Secretary of Health and Human Services in
the Federal Register on September 29, 2009 (74 Fed. Reg.
49922 et seq.)). Such study shall include an analysis of--
(A) the ability of providers of services and renal dialysis
facilities to furnish specified oral drugs or arrange for the
provision of such drugs;
(B) the ability of providers of services and renal dialysis
facilities to comply, if necessary, with applicable State
laws (such as State pharmacy licensure requirements) in order
to furnish specified oral drugs;
(C) whether appropriate quality measures exist to safeguard
care for Medicare beneficiaries being furnished specified
oral drugs by providers of services and renal dialysis
facilities; and
(D) other areas determined appropriate by the Comptroller
General.
(2) Specified oral drug defined.--For purposes of paragraph
(1), the term ``specified oral drug'' means a drug or
biological for which there is no injectable equivalent (or
other non-oral form of administration).
(b) Report.--Not later than 1 year after the date of the
enactment of this Act, the Comptroller General of the United
States shall submit to Congress a report containing the
results of the study conducted under subsection (a), together
with recommendations for such legislation and administrative
action as the Comptroller General determines appropriate.
Subtitle D--Provisions Relating to Title IV
SEC. 10401. AMENDMENTS TO SUBTITLE A.
(a) Section 4001(h)(4) and (5) of this Act is amended by
striking ``2010'' each place such appears and inserting
``2020''.
(b) Section 4002(c) of this Act is amended--
(1) by striking ``research and health screenings'' and
inserting ``research, health screenings, and initiatives'';
and
(2) by striking ``for Preventive'' and inserting
``Regarding Preventive''.
(c) Section 4004(a)(4) of this Act is amended by striking
``a Gateway'' and inserting ``an Exchange''.
SEC. 10402. AMENDMENTS TO SUBTITLE B.
(a) Section 399Z-1(a)(1(A) of the Public Health Service
Act, as added by section 4101(b) of this Act, is amended by
inserting ``and vision'' after ``oral''.
(b) Section 1861(hhh)(4)(G) of the Social Security Act, as
added by section 4103(b), is amended to read as follows:
``(G) A beneficiary shall be eligible to receive only an
initial preventive physical examination (as defined under
subsection (ww)(1)) during the 12-month period after the date
that the beneficiary's coverage begins under part B and shall
be eligible to receive personalized prevention plan services
under this subsection each year thereafter provided that the
beneficiary has not received either an initial preventive
physical examination or personalized prevention plan services
within the preceding 12-month period.''.
SEC. 10403. AMENDMENTS TO SUBTITLE C.
Section 4201 of this Act is amended--
(1) in subsection (a), by adding before the period the
following: ``, with not less than 20 percent of such grants
being awarded to rural and frontier areas'';
(2) in subsection (c)(2)(B)(vii), by striking ``both urban
and rural areas'' and inserting ``urban, rural, and frontier
areas''; and
(3) in subsection (f), by striking ``each fiscal years''
and inserting ``each of fiscal year''.
SEC. 10404. AMENDMENTS TO SUBTITLE D.
Section 399MM(2) of the Public Health Service Act, as added
by section 4303 of this Act, is amended by striking ``by
ensuring'' and inserting ``and ensuring''.
SEC. 10405. AMENDMENTS TO SUBTITLE E.
Subtitle E of title IV of this Act is amended by striking
section 4401.
SEC. 10406. AMENDMENT RELATING TO WAIVING COINSURANCE FOR
PREVENTIVE SERVICES.
Section 4104(b) of this Act is amended to read as follows:
``(b) Payment and Elimination of Coinsurance in All
Settings.--Section 1833(a)(1) of the Social Security Act (42
U.S.C. 1395l(a)(1)), as amended by section 4103(c)(1), is
amended--
``(1) in subparagraph (T), by inserting `(or 100 percent if
such services are recommended with a grade of A or B by the
United States Preventive Services Task Force for any
indication or population and are appropriate for the
individual)' after `80 percent';
``(2) in subparagraph (W)--
``(A) in clause (i), by inserting `(if such subparagraph
were applied, by substituting ``100 percent'' for ``80
percent'')' after `subparagraph (D)'; and
``(B) in clause (ii), by striking `80 percent' and
inserting `100 percent';
``(3) by striking `and' before `(X)'; and
``(4) by inserting before the semicolon at the end the
following: `, and (Y) with respect to preventive services
described in subparagraphs (A) and (B) of section
1861(ddd)(3) that are appropriate for the individual and, in
the case of such services described in subparagraph (A), are
recommended with a grade of A or B by the United States
Preventive Services Task Force for any indication or
population, the amount paid shall be 100 percent of (i)
except as provided in clause (ii), the lesser of the actual
charge for the services or the amount determined under the
fee schedule that applies to such services under this part,
and (ii) in the case of such services that are covered OPD
services (as defined in subsection (t)(1)(B)), the amount
determined under subsection (t)'.''.
SEC. 10407. BETTER DIABETES CARE.
(a) Short Title.--This section may be cited as the
``Catalyst to Better Diabetes Care Act of 2009''.
(b) National Diabetes Report Card.--
(1) In general.--The Secretary, in collaboration with the
Director of the Centers for Disease Control and Prevention
(referred to in this section as the ``Director''), shall
prepare on a biennial basis a national diabetes report card
(referred to in this section as a ``Report Card'') and, to
the extent possible, for each State.
(2) Contents.--
(A) In general.--Each Report Card shall include aggregate
health outcomes related to individuals diagnosed with
diabetes and prediabetes including--
(i) preventative care practices and quality of care;
(ii) risk factors; and
(iii) outcomes.
(B) Updated reports.--Each Report Card that is prepared
after the initial Report Card shall include trend analysis
for the Nation and, to the extent possible, for each State,
for the purpose of--
(i) tracking progress in meeting established national goals
and objectives for improving diabetes care, costs, and
prevalence (including Healthy People 2010); and
(ii) informing policy and program development.
(3) Availability.--The Secretary, in collaboration with the
Director, shall make each Report Card publicly available,
including by posting the Report Card on the Internet.
(c) Improvement of Vital Statistics Collection.--
(1) In general.--The Secretary, acting through the Director
of the Centers for Disease Control and Prevention and in
collaboration with appropriate agencies and States, shall--
(A) promote the education and training of physicians on the
importance of birth and death certificate data and how to
properly complete these documents, including the collection
of such data for diabetes and other chronic diseases;
(B) encourage State adoption of the latest standard
revisions of birth and death certificates; and
(C) work with States to re-engineer their vital statistics
systems in order to provide cost-effective, timely, and
accurate vital systems data.
(2) Death certificate additional language.--In carrying out
this subsection, the Secretary may promote improvements to
the collection of diabetes mortality data, including the
addition of a question for the individual certifying the
cause of death regarding whether the deceased had diabetes.
(d) Study on Appropriate Level of Diabetes Medical
Education.--
(1) In general.--The Secretary shall, in collaboration with
the Institute of Medicine and appropriate associations and
councils, conduct a study of the impact of diabetes on the
practice of medicine in the United States and the
appropriateness of the level of diabetes medical education
that should be required prior to licensure, board
certification, and board recertification.
(2) Report.--Not later than 2 years after the date of the
enactment of this Act, the Secretary shall submit a report on
the study under paragraph (1) to the Committees on Ways and
Means and Energy and Commerce of the House of Representatives
and the Committees on Finance and Health, Education, Labor,
and Pensions of the Senate.
(e) Authorization of Appropriations.--There are authorized
to be appropriated to carry out this section such sums as may
be necessary.
SEC. 10408. GRANTS FOR SMALL BUSINESSES TO PROVIDE
COMPREHENSIVE WORKPLACE WELLNESS PROGRAMS.
(a) Establishment.--The Secretary shall award grants to
eligible employers to provide their employees with access to
comprehensive workplace wellness programs (as described under
subsection (c)).
(b) Scope.--
(1) Duration.--The grant program established under this
section shall be conducted for a 5-year period.
(2) Eligible employer.--The term ``eligible employer''
means an employer (including a non-profit employer) that--
(A) employs less than 100 employees who work 25 hours or
greater per week; and
(B) does not provide a workplace wellness program as of the
date of enactment of this Act.
(c) Comprehensive Workplace Wellness Programs.--
(1) Criteria.--The Secretary shall develop program criteria
for comprehensive workplace wellness programs under this
section that are based on and consistent with evidence-based
research and best practices, including research and practices
as provided in the Guide to Community Preventive Services,
the Guide to Clinical Preventive Services, and the National
Registry for Effective Programs.
(2) Requirements.--A comprehensive workplace wellness
program shall be made available by an eligible employer to
all employees and include the following components:
(A) Health awareness initiatives (including health
education, preventive screenings, and health risk
assessments).
(B) Efforts to maximize employee engagement (including
mechanisms to encourage employee participation).
(C) Initiatives to change unhealthy behaviors and lifestyle
choices (including counseling, seminars, online programs, and
self-help materials).
(D) Supportive environment efforts (including workplace
policies to encourage healthy lifestyles, healthy eating,
increased physical activity, and improved mental health).
(d) Application.--An eligible employer desiring to
participate in the grant program under
[[Page H2141]]
this section shall submit an application to the Secretary, in
such manner and containing such information as the Secretary
may require, which shall include a proposal for a
comprehensive workplace wellness program that meet the
criteria and requirements described under subsection (c).
(e) Authorization of Appropriation.--For purposes of
carrying out the grant program under this section, there is
authorized to be appropriated $200,000,000 for the period of
fiscal years 2011 through 2015. Amounts appropriated pursuant
to this subsection shall remain available until expended.
SEC. 10409. CURES ACCELERATION NETWORK.
(a) Short Title.--This section may be cited as the ``Cures
Acceleration Network Act of 2009''.
(b) Requirement for the Director of NIH To Establish a
Cures Acceleration Network.--Section 402(b) of the Public
Health Service Act (42 U.S.C. 282(b)) is amended--
(1) in paragraph (22), by striking ``and'' at the end;
(2) in paragraph (23), by striking the period and inserting
``; and''; and
(3) by inserting after paragraph (23), the following:
``(24) implement the Cures Acceleration Network described
in section 402C.''.
(c) Accepting Gifts To Support the Cures Acceleration
Network.--Section 499(c)(1) of the Public Health Service Act
(42 U.S.C. 290b(c)(1)) is amended by adding at the end the
following:
``(E) The Cures Acceleration Network described in section
402C.''.
(d) Establishment of the Cures Acceleration Network.--Part
A of title IV of the Public Health Service Act is amended by
inserting after section 402B (42 U.S.C. 282b) the following:
``SEC. 402C. CURES ACCELERATION NETWORK.
``(a) Definitions.--In this section:
``(1) Biological product.--The term `biological product'
has the meaning given such term in section 351 of the Public
Health Service Act.
``(2) Drug; device.--The terms `drug' and `device' have the
meanings given such terms in section 201 of the Federal Food,
Drug, and Cosmetic Act.
``(3) High need cure.--The term `high need cure' means a
drug (as that term is defined by section 201(g)(1) of the
Federal Food, Drug, and Cosmetic Act, biological product (as
that term is defined by section 262(i)), or device (as that
term is defined by section 201(h) of the Federal Food, Drug,
and Cosmetic Act) that, in the determination of the Director
of NIH--
``(A) is a priority to diagnose, mitigate, prevent, or
treat harm from any disease or condition; and
``(B) for which the incentives of the commercial market are
unlikely to result in its adequate or timely development.
``(4) Medical product.--The term `medical product' means a
drug, device, biological product, or product that is a
combination of drugs, devices, and biological products.
``(b) Establishment of the Cures Acceleration Network.--
Subject to the appropriation of funds as described in
subsection (g), there is established within the Office of the
Director of NIH a program to be known as the Cures
Acceleration Network (referred to in this section as `CAN'),
which shall--
``(1) be under the direction of the Director of NIH, taking
into account the recommendations of a CAN Review Board
(referred to in this section as the `Board'), described in
subsection (d); and
``(2) award grants and contracts to eligible entities, as
described in subsection (e), to accelerate the development of
high need cures, including through the development of medical
products and behavioral therapies.
``(c) Functions.--The functions of the CAN are to--
``(1) conduct and support revolutionary advances in basic
research, translating scientific discoveries from bench to
bedside;
``(2) award grants and contracts to eligible entities to
accelerate the development of high need cures;
``(3) provide the resources necessary for government
agencies, independent investigators, research organizations,
biotechnology companies, academic research institutions, and
other entities to develop high need cures;
``(4) reduce the barriers between laboratory discoveries
and clinical trials for new therapies; and
``(5) facilitate review in the Food and Drug Administration
for the high need cures funded by the CAN, through activities
that may include--
``(A) the facilitation of regular and ongoing communication
with the Food and Drug Administration regarding the status of
activities conducted under this section;
``(B) ensuring that such activities are coordinated with
the approval requirements of the Food and Drug
Administration, with the goal of expediting the development
and approval of countermeasures and products; and
``(C) connecting interested persons with additional
technical assistance made available under section 565 of the
Federal Food, Drug, and Cosmetic Act.
``(d) CAN Board.--
``(1) Establishment.--There is established a Cures
Acceleration Network Review Board (referred to in this
section as the `Board'), which shall advise the Director of
NIH on the conduct of the activities of the Cures
Acceleration Network.
``(2) Membership.--
``(A) In general.--
``(i) Appointment.--The Board shall be comprised of 24
members who are appointed by the Secretary and who serve at
the pleasure of the Secretary.
``(ii) Chairperson and vice chairperson.--The Secretary
shall designate, from among the 24 members appointed under
clause (i), one Chairperson of the Board (referred to in this
section as the `Chairperson') and one Vice Chairperson.
``(B) Terms.--
``(i) In general.--Each member shall be appointed to serve
a 4-year term, except that any member appointed to fill a
vacancy occurring prior to the expiration of the term for
which the member's predecessor was appointed shall be
appointed for the remainder of such term.
``(ii) Consecutive appointments; maximum terms.--A member
may be appointed to serve not more than 3 terms on the Board,
and may not serve more than 2 such terms consecutively.
``(C) Qualifications.--
``(i) In general.--The Secretary shall appoint individuals
to the Board based solely upon the individual's established
record of distinguished service in one of the areas of
expertise described in clause (ii). Each individual appointed
to the Board shall be of distinguished achievement and have a
broad range of disciplinary interests.
``(ii) Expertise.--The Secretary shall select individuals
based upon the following requirements:
``(I) For each of the fields of--
``(aa) basic research;
``(bb) medicine;
``(cc) biopharmaceuticals;
``(dd) discovery and delivery of medical products;
``(ee) bioinformatics and gene therapy;
``(ff) medical instrumentation; and
``(gg) regulatory review and approval of medical products,
the Secretary shall select at least 1 individual who is
eminent in such fields.
``(II) At least 4 individuals shall be recognized leaders
in professional venture capital or private equity
organizations and have demonstrated experience in private
equity investing.
``(III) At least 8 individuals shall represent disease
advocacy organizations.
``(3) Ex-officio members.--
``(A) Appointment.--In addition to the 24 Board members
described in paragraph (2), the Secretary shall appoint as
ex-officio members of the Board--
``(i) a representative of the National Institutes of
Health, recommended by the Secretary of the Department of
Health and Human Services;
``(ii) a representative of the Office of the Assistant
Secretary of Defense for Health Affairs, recommended by the
Secretary of Defense;
``(iii) a representative of the Office of the Under
Secretary for Health for the Veterans Health Administration,
recommended by the Secretary of Veterans Affairs;
``(iv) a representative of the National Science Foundation,
recommended by the Chair of the National Science Board; and
``(v) a representative of the Food and Drug Administration,
recommended by the Commissioner of Food and Drugs.
``(B) Terms.--Each ex-officio member shall serve a 3-year
term on the Board, except that the Chairperson may adjust the
terms of the initial ex-officio members in order to provide
for a staggered term of appointment for all such members.
``(4) Responsibilities of the board and the director of
nih.--
``(A) Responsibilities of the board.--
``(i) In general.--The Board shall advise, and provide
recommendations to, the Director of NIH with respect to--
``(I) policies, programs, and procedures for carrying out
the duties of the Director of NIH under this section; and
``(II) significant barriers to successful translation of
basic science into clinical application (including issues
under the purview of other agencies and departments).
``(ii) Report.--In the case that the Board identifies a
significant barrier, as described in clause (i)(II), the
Board shall submit to the Secretary a report regarding such
barrier.
``(B) Responsibilities of the director of nih.--With
respect to each recommendation provided by the Board under
subparagraph (A)(i), the Director of NIH shall respond in
writing to the Board, indicating whether such Director will
implement such recommendation. In the case that the Director
of NIH indicates a recommendation of the Board will not be
implemented, such Director shall provide an explanation of
the reasons for not implementing such recommendation.
``(5) Meetings.--
``(A) In general.--The Board shall meet 4 times per
calendar year, at the call of the Chairperson.
``(B) Quorum; requirements; limitations.--
``(i) Quorum.--A quorum shall consist of a total of 13
members of the Board, excluding ex-officio members, with
diverse representation as described in clause (iii).
``(ii) Chairperson or vice chairperson.--Each meeting of
the Board shall be attended by either the Chairperson or the
Vice Chairperson.
``(iii) Diverse representation.--At each meeting of the
Board, there shall be not less than one scientist, one
representative of a disease advocacy organization, and one
representative of a professional venture capital or private
equity organization.
``(6) Compensation and travel expenses.--
``(A) Compensation.--Members shall receive compensation at
a rate to be fixed by the Chairperson but not to exceed a
rate equal to the daily equivalent of the annual rate of
basic pay prescribed for level IV of the Executive Schedule
under section 5315 of title 5, United States Code, for each
day (including travel time) during which the member is
engaged in the performance of the duties of the Board. All
members of the Board who are officers or employees of the
United States shall serve without compensation in addition to
that received for their services as officers or employees of
the United States.
[[Page H2142]]
``(B) Travel expenses.--Members of the Board shall be
allowed travel expenses, including per diem in lieu of
subsistence, at rates authorized for persons employed
intermittently by the Federal Government under section
5703(b) of title 5, United States Code, while away from their
homes or regular places of business in the performance of
services for the Board.
``(e) Grant Program.--
``(1) Supporting innovation.--To carry out the purposes
described in this section, the Director of NIH shall award
contracts, grants, or cooperative agreements to the entities
described in paragraph (2), to--
``(A) promote innovation in technologies supporting the
advanced research and development and production of high need
cures, including through the development of medical products
and behavioral therapies.
``(B) accelerate the development of high need cures,
including through the development of medical products,
behavioral therapies, and biomarkers that demonstrate the
safety or effectiveness of medical products; or
``(C) help the award recipient establish protocols that
comply with Food and Drug Administration standards and
otherwise permit the recipient to meet regulatory
requirements at all stages of development, manufacturing,
review, approval, and safety surveillance of a medical
product.
``(2) Eligible entities.--To receive assistance under
paragraph (1), an entity shall--
``(A) be a public or private entity, which may include a
private or public research institution, an institution of
higher education, a medical center, a biotechnology company,
a pharmaceutical company, a disease advocacy organization, a
patient advocacy organization, or an academic research
institution;
``(B) submit an application containing--
``(i) a detailed description of the project for which the
entity seeks such grant or contract;
``(ii) a timetable for such project;
``(iii) an assurance that the entity will submit--
``(I) interim reports describing the entity's--
``(aa) progress in carrying out the project; and
``(bb) compliance with all provisions of this section and
conditions of receipt of such grant or contract; and
``(II) a final report at the conclusion of the grant
period, describing the outcomes of the project; and
``(iv) a description of the protocols the entity will
follow to comply with Food and Drug Administration standards
and regulatory requirements at all stages of development,
manufacturing, review, approval, and safety surveillance of a
medical product; and
``(C) provide such additional information as the Director
of NIH may require.
``(3) Awards.--
``(A) The cures acceleration partnership awards.--
``(i) Initial award amount.--Each award under this
subparagraph shall be not more than $15,000,000 per project
for the first fiscal year for which the project is funded,
which shall be payable in one payment.
``(ii) Funding in subsequent fiscal years.--An eligible
entity receiving an award under clause (i) may apply for
additional funding for such project by submitting to the
Director of NIH the information required under subparagraphs
(B) and (C) of paragraph (2). The Director may fund a project
of such eligible entity in an amount not to exceed
$15,000,000 for a fiscal year subsequent to the initial award
under clause (i).
``(iii) Matching funds.--As a condition for receiving an
award under this subsection, an eligible entity shall
contribute to the project non-Federal funds in the amount of
$1 for every $3 awarded under clauses (i) and (ii), except
that the Director of NIH may waive or modify such matching
requirement in any case where the Director determines that
the goals and objectives of this section cannot adequately be
carried out unless such requirement is waived.
``(B) The cures acceleration grant awards.--
``(i) Initial award amount.--Each award under this
subparagraph shall be not more than $15,000,000 per project
for the first fiscal year for which the project is funded,
which shall be payable in one payment.
``(ii) Funding in subsequent fiscal years.--An eligible
entity receiving an award under clause (i) may apply for
additional funding for such project by submitting to the
Board the information required under subparagraphs (B) and
(C) of paragraph (2). The Director of NIH may fund a project
of such eligible entity in an amount not to exceed
$15,000,000 for a fiscal year subsequent to the initial award
under clause (i).
``(C) The cures acceleration flexible research awards.--If
the Director of NIH determines that the goals and objectives
of this section cannot adequately be carried out through a
contract, grant, or cooperative agreement, the Director of
NIH shall have flexible research authority to use other
transactions to fund projects in accordance with the terms
and conditions of this section. Awards made under such
flexible research authority for a fiscal year shall not
exceed 20 percent of the total funds appropriated under
subsection (g)(1) for such fiscal year.
``(4) Suspension of awards for defaults, noncompliance with
provisions and plans, and diversion of funds; repayment of
funds.--The Director of NIH may suspend the award to any
entity upon noncompliance by such entity with provisions and
plans under this section or diversion of funds.
``(5) Audits.--The Director of NIH may enter into
agreements with other entities to conduct periodic audits of
the projects funded by grants or contracts awarded under this
subsection.
``(6) Closeout procedures.--At the end of a grant or
contract period, a recipient shall follow the closeout
procedures under section 74.71 of title 45, Code of Federal
Regulations (or any successor regulation).
``(7) Review.--A determination by the Director of NIH as to
whether a drug, device, or biological product is a high need
cure (for purposes of subsection (a)(3)) shall not be subject
to judicial review.
``(f) Competitive Basis of Awards.--Any grant, cooperative
agreement, or contract awarded under this section shall be
awarded on a competitive basis.
``(g) Authorization of Appropriations.--
``(1) In general.--For purposes of carrying out this
section, there are authorized to be appropriated $500,000,000
for fiscal year 2010, and such sums as may be necessary for
subsequent fiscal years. Funds appropriated under this
section shall be available until expended.
``(2) Limitation on use of funds otherwise appropriated.--
No funds appropriated under this Act, other than funds
appropriated under paragraph (1), may be allocated to the
Cures Acceleration Network.''.
SEC. 10410. CENTERS OF EXCELLENCE FOR DEPRESSION.
(a) Short Title.--This section may be cited as the
``Establishing a Network of Health-Advancing National Centers
of Excellence for Depression Act of 2009'' or the ``ENHANCED
Act of 2009''.
(b) Centers of Excellence for Depression.--Subpart 3 of
part B of title V of the Public Health Service Act (42 U.S.C.
290bb et seq.) is amended by inserting after section 520A the
following:
``SEC. 520B. NATIONAL CENTERS OF EXCELLENCE FOR DEPRESSION.
``(a) Depressive Disorder Defined.--In this section, the
term `depressive disorder' means a mental or brain disorder
relating to depression, including major depression, bipolar
disorder, and related mood disorders.
``(b) Grant Program.--
``(1) In general.--The Secretary, acting through the
Administrator, shall award grants on a competitive basis to
eligible entities to establish national centers of excellence
for depression (referred to in this section as `Centers'),
which shall engage in activities related to the treatment of
depressive disorders.
``(2) Allocation of awards.--If the funds authorized under
subsection (f) are appropriated in the amounts provided for
under such subsection, the Secretary shall allocate such
amounts so that--
``(A) not later than 1 year after the date of enactment of
the ENHANCED Act of 2009, not more than 20 Centers may be
established; and
``(B) not later than September 30, 2016, not more than 30
Centers may be established.
``(3) Grant period.--
``(A) In general.--A grant awarded under this section shall
be for a period of 5 years.
``(B) Renewal.--A grant awarded under subparagraph (A) may
be renewed, on a competitive basis, for 1 additional 5-year
period, at the discretion of the Secretary. In determining
whether to renew a grant, the Secretary shall consider the
report cards issued under subsection (e)(2).
``(4) Use of funds.--Grant funds awarded under this
subsection shall be used for the establishment and ongoing
activities of the recipient of such funds.
``(5) Eligible entities.--
``(A) Requirements.--To be eligible to receive a grant
under this section, an entity shall--
``(i) be an institution of higher education or a public or
private nonprofit research institution; and
``(ii) submit an application to the Secretary at such time
and in such manner as the Secretary may require, as described
in subparagraph (B).
``(B) Application.--An application described in
subparagraph (A)(ii) shall include--
``(i) evidence that such entity--
``(I) provides, or is capable of coordinating with other
entities to provide, comprehensive health services with a
focus on mental health services and subspecialty expertise
for depressive disorders;
``(II) collaborates with other mental health providers, as
necessary, to address co-occurring mental illnesses;
``(III) is capable of training health professionals about
mental health; and
``(ii) such other information, as the Secretary may
require.
``(C) Priorities.--In awarding grants under this section,
the Secretary shall give priority to eligible entities that
meet 1 or more of the following criteria:
``(i) Demonstrated capacity and expertise to serve the
targeted population.
``(ii) Existing infrastructure or expertise to provide
appropriate, evidence-based and culturally and linguistically
competent services.
``(iii) A location in a geographic area with
disproportionate numbers of underserved and at-risk
populations in medically underserved areas and health
professional shortage areas.
``(iv) Proposed innovative approaches for outreach to
initiate or expand services.
``(v) Use of the most up-to-date science, practices, and
interventions available.
``(vi) Demonstrated capacity to establish cooperative and
collaborative agreements with community mental health centers
and other community entities to provide mental health,
social, and human services to individuals with depressive
disorders.
``(6) National coordinating center.--
``(A) In general.--The Secretary, acting through the
Administrator, shall designate 1 recipient of a grant under
this section to be the coordinating center of excellence for
depression (referred to in this section as the `coordinating
center'). The Secretary shall select such coordinating center
on a competitive basis, based upon the demonstrated capacity
of such center to perform the duties described in
subparagraph (C).
[[Page H2143]]
``(B) Application.--A Center that has been awarded a grant
under paragraph (1) may apply for designation as the
coordinating center by submitting an application to the
Secretary at such time, in such manner, and containing such
information as the Secretary may require.
``(C) Duties.--The coordinating center shall--
``(i) develop, administer, and coordinate the network of
Centers under this section;
``(ii) oversee and coordinate the national database
described in subsection (d);
``(iii) lead a strategy to disseminate the findings and
activities of the Centers through such database; and
``(iv) serve as a liaison with the Administration, the
National Registry of Evidence-based Programs and Practices of
the Administration, and any Federal interagency or
interagency forum on mental health.
``(7) Matching funds.--The Secretary may not award a grant
or contract under this section to an entity unless the entity
agrees that it will make available (directly or through
contributions from other public or private entities) non-
Federal contributions toward the activities to be carried out
under the grant or contract in an amount equal to $1 for each
$5 of Federal funds provided under the grant or contract.
Such non-Federal matching funds may be provided directly or
through donations from public or private entities and may be
in cash or in-kind, fairly evaluated, including plant,
equipment, or services.
``(c) Activities of the Centers.--Each Center shall carry
out the following activities:
``(1) General activities.--Each Center shall--
``(A) integrate basic, clinical, or health services
interdisciplinary research and practice in the development,
implementation, and dissemination of evidence-based
interventions;
``(B) involve a broad cross-section of stakeholders, such
as researchers, clinicians, consumers, families of consumers,
and voluntary health organizations, to develop a research
agenda and disseminate findings, and to provide support in
the implementation of evidence-based practices;
``(C) provide training and technical assistance to mental
health professionals, and engage in and disseminate
translational research with a focus on meeting the needs of
individuals with depressive disorders; and
``(D) educate policy makers, employers, community leaders,
and the public about depressive disorders to reduce stigma
and raise awareness of treatments.
``(2) Improved treatment standards, clinical guidelines,
diagnostic protocols, and care coordination practice.--Each
Center shall collaborate with other Centers in the network
to--
``(A) develop and implement treatment standards, clinical
guidelines, and protocols that emphasize primary prevention,
early intervention, treatment for, and recovery from,
depressive disorders;
``(B) foster communication with other providers attending
to co-occurring physical health conditions such as
cardiovascular, diabetes, cancer, and substance abuse
disorders;
``(C) leverage available community resources, develop and
implement improved self-management programs, and, when
appropriate, involve family and other providers of social
support in the development and implementation of care plans;
and
``(D) use electronic health records and telehealth
technology to better coordinate and manage, and improve
access to, care, as determined by the coordinating center.
``(3) Translational research through collaboration of
centers and community-based organizations.--Each Center
shall--
``(A) demonstrate effective use of a public-private
partnership to foster collaborations among members of the
network and community-based organizations such as community
mental health centers and other social and human services
providers;
``(B) expand interdisciplinary, translational, and patient-
oriented research and treatment; and
``(C) coordinate with accredited academic programs to
provide ongoing opportunities for the professional and
continuing education of mental health providers.
``(d) National Database.--
``(1) In general.--The coordinating center shall establish
and maintain a national, publicly available database to
improve prevention programs, evidence-based interventions,
and disease management programs for depressive disorders,
using data collected from the Centers, as described in
paragraph (2).
``(2) Data collection.--Each Center shall submit data
gathered at such center, as appropriate, to the coordinating
center regarding--
``(A) the prevalence and incidence of depressive disorders;
``(B) the health and social outcomes of individuals with
depressive disorders;
``(C) the effectiveness of interventions designed, tested,
and evaluated;
``(D) other information, as the Secretary may require.
``(3) Submission of data to the administrator.--The
coordinating center shall submit to the Administrator the
data and financial information gathered under paragraph (2).
``(4) Publication using data from the database.--A Center,
or an individual affiliated with a Center, may publish
findings using the data described in paragraph (2) only if
such center submits such data to the coordinating center, as
required under such paragraph.
``(e) Establishment of Standards; Report Cards and
Recommendations; Third Party Review.--
``(1) Establishment of standards.--The Secretary, acting
through the Administrator, shall establish performance
standards for--
``(A) each Center; and
``(B) the network of Centers as a whole.
``(2) Report cards.--The Secretary, acting through the
Administrator, shall--
``(A) for each Center, not later than 3 years after the
date on which such center of excellence is established and
annually thereafter, issue a report card to the coordinating
center to rate the performance of such Center; and
``(B) not later than 3 years after the date on which the
first grant is awarded under subsection (b)(1) and annually
thereafter, issue a report card to Congress to rate the
performance of the network of centers of excellence as a
whole.
``(3) Recommendations.--Based upon the report cards
described in paragraph (2), the Secretary shall, not later
than September 30, 2015--
``(A) make recommendations to the Centers regarding
improvements such centers shall make; and
``(B) make recommendations to Congress for expanding the
Centers to serve individuals with other types of mental
disorders.
``(4) Third party review.--Not later than 3 years after the
date on which the first grant is awarded under subsection
(b)(1) and annually thereafter, the Secretary shall arrange
for an independent third party to conduct an evaluation of
the network of Centers to ensure that such centers are
meeting the goals of this section.
``(f) Authorization of Appropriations.--
``(1) In general.--To carry out this section, there are
authorized to be appropriated--
``(A) $100,000,000 for each of the fiscal years 2011
through 2015; and
``(B) $150,000,000 for each of the fiscal years 2016
through 2020.
``(2) Allocation of funds authorized.--Of the amount
appropriated under paragraph (1) for a fiscal year, the
Secretary shall determine the allocation of each Center
receiving a grant under this section, but in no case may the
allocation be more than $5,000,000, except that the Secretary
may allocate not more than $10,000,000 to the coordinating
center.''.
SEC. 10411. PROGRAMS RELATING TO CONGENITAL HEART DISEASE.
(a) Short Title.--This subtitle may be cited as the
``Congenital Heart Futures Act''.
(b) Programs Relating to Congenital Heart Disease.--
(1) National congenital heart disease surveillance
system.--Part P of title III of the Public Health Service Act
(42 U.S.C. 280g et seq.), as amended by section 5405, is
further amended by adding at the end the following:
``SEC. 399V-2. NATIONAL CONGENITAL HEART DISEASE SURVEILLANCE
SYSTEM.
``(a) In General.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
may--
``(1) enhance and expand infrastructure to track the
epidemiology of congenital heart disease and to organize such
information into a nationally-representative, population-
based surveillance system that compiles data concerning
actual occurrences of congenital heart disease, to be known
as the `National Congenital Heart Disease Surveillance
System'; or
``(2) award a grant to one eligible entity to undertake the
activities described in paragraph (1).
``(b) Purpose.--The purpose of the Congenital Heart Disease
Surveillance System shall be to facilitate further research
into the types of health services patients use and to
identify possible areas for educational outreach and
prevention in accordance with standard practices of the
Centers for Disease Control and Prevention.
``(c) Content.--The Congenital Heart Disease Surveillance
System--
``(1) may include information concerning the incidence and
prevalence of congenital heart disease in the United States;
``(2) may be used to collect and store data on congenital
heart disease, including data concerning--
``(A) demographic factors associated with congenital heart
disease, such as age, race, ethnicity, sex, and family
history of individuals who are diagnosed with the disease;
``(B) risk factors associated with the disease;
``(C) causation of the disease;
``(D) treatment approaches; and
``(E) outcome measures, such that analysis of the outcome
measures will allow derivation of evidence-based best
practices and guidelines for congenital heart disease
patients; and
``(3) may ensure the collection and analysis of
longitudinal data related to individuals of all ages with
congenital heart disease, including infants, young children,
adolescents, and adults of all ages.
``(d) Public Access.--The Congenital Heart Disease
Surveillance System shall be made available to the public, as
appropriate, including congenital heart disease researchers.
``(e) Patient Privacy.--The Secretary shall ensure that the
Congenital Heart Disease Surveillance System is maintained in
a manner that complies with the regulations promulgated under
section 264 of the Health Insurance Portability and
Accountability Act of 1996.
``(f) Eligibility for Grant.--To be eligible to receive a
grant under subsection (a)(2), an entity shall--
``(1) be a public or private nonprofit entity with
specialized experience in congenital heart disease; and
``(2) submit to the Secretary an application at such time,
in such manner, and containing such information as the
Secretary may require.''.
(2) Congenital heart disease research.--Subpart 2 of part C
of title IV of the Public Health Service Act (42 U.S.C. 285b
et seq.) is amended by adding at the end the following:
``SEC. 425. CONGENITAL HEART DISEASE.
``(a) In General.--The Director of the Institute may
expand, intensify, and coordinate research and related
activities of the Institute
[[Page H2144]]
with respect to congenital heart disease, which may include
congenital heart disease research with respect to--
``(1) causation of congenital heart disease, including
genetic causes;
``(2) long-term outcomes in individuals with congenital
heart disease, including infants, children, teenagers,
adults, and elderly individuals;
``(3) diagnosis, treatment, and prevention;
``(4) studies using longitudinal data and retrospective
analysis to identify effective treatments and outcomes for
individuals with congenital heart disease; and
``(5) identifying barriers to life-long care for
individuals with congenital heart disease.
``(b) Coordination of Research Activities.--The Director of
the Institute may coordinate research efforts related to
congenital heart disease among multiple research institutions
and may develop research networks.
``(c) Minority and Medically Underserved Communities.--In
carrying out the activities described in this section, the
Director of the Institute shall consider the application of
such research and other activities to minority and medically
underserved communities.''.
(c) Authorization of Appropriations.--There are authorized
to be appropriated to carry out the amendments made by this
section such sums as may be necessary for each of fiscal
years 2011 through 2015.
SEC. 10412. AUTOMATED DEFIBRILLATION IN ADAM'S MEMORY ACT.
Section 312 of the Public Health Service Act (42 U.S.C.
244) is amended--
(1) in subsection (c)(6), after ``clearinghouse'' insert
``, that shall be administered by an organization that has
substantial expertise in pediatric education, pediatric
medicine, and electrophysiology and sudden death,''; and
(2) in the first sentence of subsection (e), by striking
``fiscal year 2003'' and all that follows through ``2006''
and inserting ``for each of fiscal years 2003 through 2014''.
SEC. 10413. YOUNG WOMEN'S BREAST HEALTH AWARENESS AND SUPPORT
OF YOUNG WOMEN DIAGNOSED WITH BREAST CANCER.
(a) Short Title.--This section may be cited as the ``Young
Women's Breast Health Education and Awareness Requires
Learning Young Act of 2009'' or the ``EARLY Act''.
(b) Amendment.--Title III of the Public Health Service Act
(42 U.S.C. 241 et seq.), as amended by this Act, is further
amended by adding at the end the following:
``PART V--PROGRAMS RELATING TO BREAST HEALTH AND CANCER
``SEC. 399NN. YOUNG WOMEN'S BREAST HEALTH AWARENESS AND
SUPPORT OF YOUNG WOMEN DIAGNOSED WITH BREAST
CANCER.
``(a) Public Education Campaign.--
``(1) In general.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall conduct a national evidence-based education campaign to
increase awareness of young women's knowledge regarding--
``(A) breast health in young women of all racial, ethnic,
and cultural backgrounds;
``(B) breast awareness and good breast health habits;
``(C) the occurrence of breast cancer and the general and
specific risk factors in women who may be at high risk for
breast cancer based on familial, racial, ethnic, and cultural
backgrounds such as Ashkenazi Jewish populations;
``(D) evidence-based information that would encourage young
women and their health care professional to increase early
detection of breast cancers; and
``(E) the availability of health information and other
resources for young women diagnosed with breast cancer.
``(2) Evidence-based, age appropriate messages.--The
campaign shall provide evidence-based, age-appropriate
messages and materials as developed by the Centers for
Disease Control and Prevention and the Advisory Committee
established under paragraph (4).
``(3) Media campaign.--In conducting the education campaign
under paragraph (1), the Secretary shall award grants to
entities to establish national multimedia campaigns oriented
to young women that may include advertising through
television, radio, print media, billboards, posters, all
forms of existing and especially emerging social networking
media, other Internet media, and any other medium determined
appropriate by the Secretary.
``(4) Advisory committee.--
``(A) Establishment.--Not later than 60 days after the date
of the enactment of this section, the Secretary, acting
through the Director of the Centers for Disease Control and
Prevention, shall establish an advisory committee to assist
in creating and conducting the education campaigns under
paragraph (1) and subsection (b)(1).
``(B) Membership.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall appoint to the advisory committee under subparagraph
(A) such members as deemed necessary to properly advise the
Secretary, and shall include organizations and individuals
with expertise in breast cancer, disease prevention, early
detection, diagnosis, public health, social marketing,
genetic screening and counseling, treatment, rehabilitation,
palliative care, and survivorship in young women.
``(b) Health Care Professional Education Campaign.--The
Secretary, acting through the Director of the Centers for
Disease Control and Prevention, and in consultation with the
Administrator of the Health Resources and Services
Administration, shall conduct an education campaign among
physicians and other health care professionals to increase
awareness--
``(1) of breast health, symptoms, and early diagnosis and
treatment of breast cancer in young women, including specific
risk factors such as family history of cancer and women that
may be at high risk for breast cancer, such as Ashkenazi
Jewish population;
``(2) on how to provide counseling to young women about
their breast health, including knowledge of their family
cancer history and importance of providing regular clinical
breast examinations;
``(3) concerning the importance of discussing healthy
behaviors, and increasing awareness of services and programs
available to address overall health and wellness, and making
patient referrals to address tobacco cessation, good
nutrition, and physical activity;
``(4) on when to refer patients to a health care provider
with genetics expertise;
``(5) on how to provide counseling that addresses long-term
survivorship and health concerns of young women diagnosed
with breast cancer; and
``(6) on when to provide referrals to organizations and
institutions that provide credible health information and
substantive assistance and support to young women diagnosed
with breast cancer.
``(c) Prevention Research Activities.--The Secretary,
acting through--
``(1) the Director of the Centers for Disease Control and
Prevention, shall conduct prevention research on breast
cancer in younger women, including--
``(A) behavioral, survivorship studies, and other research
on the impact of breast cancer diagnosis on young women;
``(B) formative research to assist with the development of
educational messages and information for the public, targeted
populations, and their families about breast health, breast
cancer, and healthy lifestyles;
``(C) testing and evaluating existing and new social
marketing strategies targeted at young women; and
``(D) surveys of health care providers and the public
regarding knowledge, attitudes, and practices related to
breast health and breast cancer prevention and control in
high-risk populations; and
``(2) the Director of the National Institutes of Health,
shall conduct research to develop and validate new screening
tests and methods for prevention and early detection of
breast cancer in young women.
``(d) Support for Young Women Diagnosed With Breast
Cancer.--
``(1) In general.--The Secretary shall award grants to
organizations and institutions to provide health information
from credible sources and substantive assistance directed to
young women diagnosed with breast cancer and pre-neoplastic
breast diseases.
``(2) Priority.--In making grants under paragraph (1), the
Secretary shall give priority to applicants that deal
specifically with young women diagnosed with breast cancer
and pre-neoplastic breast disease.
``(e) No Duplication of Effort.--In conducting an education
campaign or other program under subsections (a), (b), (c), or
(d), the Secretary shall avoid duplicating other existing
Federal breast cancer education efforts.
``(f) Measurement; Reporting.--The Secretary, acting
through the Director of the Centers for Disease Control and
Prevention, shall--
``(1) measure--
``(A) young women's awareness regarding breast health,
including knowledge of family cancer history, specific risk
factors and early warning signs, and young women's proactive
efforts at early detection;
``(B) the number or percentage of young women utilizing
information regarding lifestyle interventions that foster
healthy behaviors;
``(C) the number or percentage of young women receiving
regular clinical breast exams; and
``(D) the number or percentage of young women who perform
breast self exams, and the frequency of such exams, before
the implementation of this section;
``(2) not less than every 3 years, measure the impact of
such activities; and
``(3) submit reports to the Congress on the results of such
measurements.
``(g) Definition.--In this section, the term `young women'
means women 15 to 44 years of age.
``(h) Authorization of Appropriations.--To carry out
subsections (a), (b), (c)(1), and (d), there are authorized
to be appropriated $9,000,000 for each of the fiscal years
2010 through 2014.''.
Subtitle E--Provisions Relating to Title V
SEC. 10501. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT, THE
SOCIAL SECURITY ACT, AND TITLE V OF THIS ACT.
(a) Section 5101 of this Act is amended--
(1) in subsection (c)(2)(B)(i)(II), by inserting ``,
including representatives of small business and self-employed
individuals'' after ``employers'';
(2) in subsection (d)(4)(A)--
(A) by redesignating clause (iv) as clause (v); and
(B) by inserting after clause (iii) the following:
``(iv) An analysis of, and recommendations for, eliminating
the barriers to entering and staying in primary care,
including provider compensation.''; and
(3) in subsection (i)(2)(B), by inserting ``optometrists,
ophthalmologists,'' after ``occupational therapists,''.
(b) Subtitle B of title V of this Act is amended by adding
at the end the following:
[[Page H2145]]
``SEC. 5104. INTERAGENCY TASK FORCE TO ASSESS AND IMPROVE
ACCESS TO HEALTH CARE IN THE STATE OF ALASKA.
``(a) Establishment.--There is established a task force to
be known as the `Interagency Access to Health Care in Alaska
Task Force' (referred to in this section as the `Task
Force').
``(b) Duties.--The Task Force shall--
``(1) assess access to health care for beneficiaries of
Federal health care systems in Alaska; and
``(2) develop a strategy for the Federal Government to
improve delivery of health care to Federal beneficiaries in
the State of Alaska.
``(c) Membership.--The Task Force shall be comprised of
Federal members who shall be appointed, not later than 45
days after the date of enactment of this Act, as follows:
``(1) The Secretary of Health and Human Services shall
appoint one representative of each of the following:
``(A) The Department of Health and Human Services.
``(B) The Centers for Medicare and Medicaid Services.
``(C) The Indian Health Service.
``(2) The Secretary of Defense shall appoint one
representative of the TRICARE Management Activity.
``(3) The Secretary of the Army shall appoint one
representative of the Army Medical Department.
``(4) The Secretary of the Air Force shall appoint one
representative of the Air Force, from among officers at the
Air Force performing medical service functions.
``(5) The Secretary of Veterans Affairs shall appoint one
representative of each of the following:
``(A) The Department of Veterans Affairs.
``(B) The Veterans Health Administration.
``(6) The Secretary of Homeland Security shall appoint one
representative of the United States Coast Guard.
``(d) Chairperson.--One chairperson of the Task Force shall
be appointed by the Secretary at the time of appointment of
members under subsection (c), selected from among the members
appointed under paragraph (1).
``(e) Meetings.--The Task Force shall meet at the call of
the chairperson.
``(f) Report.--Not later than 180 days after the date of
enactment of this Act, the Task Force shall submit to
Congress a report detailing the activities of the Task Force
and containing the findings, strategies, recommendations,
policies, and initiatives developed pursuant to the duty
described in subsection (b)(2). In preparing such report, the
Task Force shall consider completed and ongoing efforts by
Federal agencies to improve access to health care in the
State of Alaska.
``(g) Termination.--The Task Force shall be terminated on
the date of submission of the report described in subsection
(f).''.
(c) Section 399V of the Public Health Service Act, as added
by section 5313, is amended--
(1) in subsection (b)(4), by striking ``identify, educate,
refer, and enroll'' and inserting ``identify and refer''; and
(2) in subsection (k)(1), by striking ``, as defined by the
Department of Labor as Standard Occupational Classification
[21-1094]''.
(d) Section 738(a)(3) of the Public Health Service Act (42
U.S.C. 293b(a)(3)) is amended by inserting ``schools offering
physician assistant education programs,'' after ``public
health,''.
(e) Subtitle D of title V of this Act is amended by adding
at the end the following:
``SEC. 5316. DEMONSTRATION GRANTS FOR FAMILY NURSE
PRACTITIONER TRAINING PROGRAMS.
``(a) Establishment of Program.--The Secretary of Health
and Human Services (referred to in this section as the
`Secretary') shall establish a training demonstration program
for family nurse practitioners (referred to in this section
as the `program') to employ and provide 1-year training for
nurse practitioners who have graduated from a nurse
practitioner program for careers as primary care providers in
Federally qualified health centers (referred to in this
section as `FQHCs') and nurse-managed health clinics
(referred to in this section as `NMHCs').
``(b) Purpose.--The purpose of the program is to enable
each grant recipient to--
``(1) provide new nurse practitioners with clinical
training to enable them to serve as primary care providers in
FQHCs and NMHCs;
``(2) train new nurse practitioners to work under a model
of primary care that is consistent with the principles set
forth by the Institute of Medicine and the needs of
vulnerable populations; and
``(3) create a model of FQHC and NMHC training for nurse
practitioners that may be replicated nationwide.
``(c) Grants.--The Secretary shall award 3-year grants to
eligible entities that meet the requirements established by
the Secretary, for the purpose of operating the nurse
practitioner primary care programs described in subsection
(a) in such entities.
``(d) Eligible Entities.--To be eligible to receive a grant
under this section, an entity shall--
``(1)(A) be a FQHC as defined in section 1861(aa) of the
Social Security Act (42 U.S.C. 1395x(aa)); or
``(B) be a nurse-managed health clinic, as defined in
section 330A-1 of the Public Health Service Act (as added by
section 5208 of this Act); and
``(2) submit to the Secretary an application at such time,
in such manner, and containing such information as the
Secretary may require.
``(e) Priority in Awarding Grants.--In awarding grants
under this section, the Secretary shall give priority to
eligible entities that--
``(1) demonstrate sufficient infrastructure in size, scope,
and capacity to undertake the requisite training of a minimum
of 3 nurse practitioners per year, and to provide to each
awardee 12 full months of full-time, paid employment and
benefits consistent with the benefits offered to other full-
time employees of such entity;
``(2) will assign not less than 1 staff nurse practitioner
or physician to each of 4 precepted clinics;
``(3) will provide to each awardee specialty rotations,
including specialty training in prenatal care and women's
health, adult and child psychiatry, orthopedics, geriatrics,
and at least 3 other high-volume, high-burden specialty
areas;
``(4) provide sessions on high-volume, high-risk health
problems and have a record of training health care
professionals in the care of children, older adults, and
underserved populations; and
``(5) collaborate with other safety net providers, schools,
colleges, and universities that provide health professions
training.
``(f) Eligibility of Nurse Practitioners.--
``(1) In general.--To be eligible for acceptance to a
program funded through a grant awarded under this section, an
individual shall--
``(A) be licensed or eligible for licensure in the State in
which the program is located as an advanced practice
registered nurse or advanced practice nurse and be eligible
or board-certified as a family nurse practitioner; and
``(B) demonstrate commitment to a career as a primary care
provider in a FQHC or in a NMHC.
``(2) Preference.--In selecting awardees under the program,
each grant recipient shall give preference to bilingual
candidates that meet the requirements described in paragraph
(1).
``(3) Deferral of certain service.--The starting date of
required service of individuals in the National Health
Service Corps Service program under title II of the Public
Health Service Act (42 U.S.C. 202 et seq.) who receive
training under this section shall be deferred until the date
that is 22 days after the date of completion of the program.
``(g) Grant Amount.--Each grant awarded under this section
shall be in an amount not to exceed $600,000 per year. A
grant recipient may carry over funds from 1 fiscal year to
another without obtaining approval from the Secretary.
``(h) Technical Assistance Grants.--The Secretary may award
technical assistance grants to 1 or more FQHCs or NMHCs that
have demonstrated expertise in establishing a nurse
practitioner residency training program. Such technical
assistance grants shall be for the purpose of providing
technical assistance to other recipients of grants under
subsection (c).
``(i) Authorization of Appropriations.--To carry out this
section, there is authorized to be appropriated such sums as
may be necessary for each of fiscal years 2011 through
2014.''.
(f)(1) Section 399W of the Public Health Service Act, as
added by section 5405, is redesignated as section 399V-1.
(2) Section 399V-1 of the Public Health Service Act, as so
redesignated, is amended in subsection (b)(2)(A) by striking
``and the departments of 1 or more health professions schools
in the State that train providers in primary care'' and
inserting ``and the departments that train providers in
primary care in 1 or more health professions schools in the
State''.
(3) Section 934 of the Public Health Service Act, as added
by section 3501, is amended by striking ``399W'' each place
such term appears and inserting ``399V-1''.
(4) Section 935(b) of the Public Health Service Act, as
added by section 3503, is amended by striking ``399W'' and
inserting ``399V-1''.
(g) Part P of title III of the Public Health Service Act 42
U.S.C. 280g et seq.), as amended by section 10411, is amended
by adding at the end the following:
``SEC. 399V-3. NATIONAL DIABETES PREVENTION PROGRAM.
``(a) In General.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall establish a national diabetes prevention program
(referred to in this section as the `program') targeted at
adults at high risk for diabetes in order to eliminate the
preventable burden of diabetes.
``(b) Program Activities.--The program described in
subsection (a) shall include--
``(1) a grant program for community-based diabetes
prevention program model sites;
``(2) a program within the Centers for Disease Control and
Prevention to determine eligibility of entities to deliver
community-based diabetes prevention services;
``(3) a training and outreach program for lifestyle
intervention instructors; and
``(4) evaluation, monitoring and technical assistance, and
applied research carried out by the Centers for Disease
Control and Prevention.
``(c) Eligible Entities.--To be eligible for a grant under
subsection (b)(1), an entity shall be a State or local health
department, a tribal organization, a national network of
community-based non-profits focused on health and wellbeing,
an academic institution, or other entity, as the Secretary
determines.
``(d) Authorization of Appropriations.--For the purpose of
carrying out this section, there are authorized to be
appropriated such sums as may be necessary for each of fiscal
years 2010 through 2014.''.
(h) The provisions of, and amendment made by, section
5501(c) of this Act are repealed.
(i)(1) The provisions of, and amendments made by, section
5502 of this Act are repealed.
(2)(A) Section 1861(aa)(3)(A) of the Social Security Act
(42 U.S.C. 1395w(aa)(3)(A)) is amended to read as follows:
``(A) services of the type described in subparagraphs (A)
through (C) of paragraph (1) and preventive services (as
defined in section 1861(ddd)(3)); and''.
(B) The amendment made by subparagraph (A) shall apply to
services furnished on or after January 1, 2011.
[[Page H2146]]
(3)(A) Section 1834 of the Social Security Act (42 U.S.C.
1395m), as amended by section 4105, is amended by adding at
the end the following new subsection:
``(o) Development and Implementation of Prospective Payment
System.--
``(1) Development.--
``(A) In general.--The Secretary shall develop a
prospective payment system for payment for Federally
qualified health center services furnished by Federally
qualified health centers under this title. Such system shall
include a process for appropriately describing the services
furnished by Federally qualified health centers and shall
establish payment rates for specific payment codes based on
such appropriate descriptions of services. Such system shall
be established to take into account the type, intensity, and
duration of services furnished by Federally qualified health
centers. Such system may include adjustments, including
geographic adjustments, determined appropriate by the
Secretary.
``(B) Collection of data and evaluation.--By not later than
January 1, 2011, the Secretary shall require Federally
qualified health centers to submit to the Secretary such
information as the Secretary may require in order to develop
and implement the prospective payment system under this
subsection, including the reporting of services using HCPCS
codes.
``(2) Implementation.--
``(A) In general.--Notwithstanding section 1833(a)(3)(A),
the Secretary shall provide, for cost reporting periods
beginning on or after October 1, 2014, for payments of
prospective payment rates for Federally qualified health
center services furnished by Federally qualified health
centers under this title in accordance with the prospective
payment system developed by the Secretary under paragraph
(1).
``(B) Payments.--
``(i) Initial payments.--The Secretary shall implement such
prospective payment system so that the estimated aggregate
amount of prospective payment rates (determined prior to the
application of section 1833(a)(1)(Z)) under this title for
Federally qualified health center services in the first year
that such system is implemented is equal to 100 percent of
the estimated amount of reasonable costs (determined without
the application of a per visit payment limit or productivity
screen and prior to the application of section
1866(a)(2)(A)(ii)) that would have occurred for such services
under this title in such year if the system had not been
implemented.
``(ii) Payments in subsequent years.--Payment rates in
years after the year of implementation of such system shall
be the payment rates in the previous year increased--
``(I) in the first year after implementation of such
system, by the percentage increase in the MEI (as defined in
section 1842(i)(3)) for the year involved; and
``(II) in subsequent years, by the percentage increase in a
market basket of Federally qualified health center goods and
services as promulgated through regulations, or if such an
index is not available, by the percentage increase in the MEI
(as defined in section 1842(i)(3)) for the year involved.
``(C) Preparation for pps implementation.--Notwithstanding
any other provision of law, the Secretary may establish and
implement by program instruction or otherwise the payment
codes to be used under the prospective payment system under
this section.''.
(B) Section 1833(a)(1) of the Social Security Act (42
U.S.C. 1395l(a)(1)), as amended by section 4104, is amended--
(i) by striking ``and'' before ``(Y)''; and
(ii) by inserting before the semicolon at the end the
following: ``, and (Z) with respect to Federally qualified
health center services for which payment is made under
section 1834(o), the amounts paid shall be 80 percent of the
lesser of the actual charge or the amount determined under
such section''.
(C) Section 1833(a) of the Social Security Act (42 U.S.C.
1395l(a)) is amended--
(i) in paragraph (3)(B)(i)--
(I) by inserting ``(I)'' after ``otherwise been provided'';
and
(II) by inserting ``, or (II) in the case of such services
furnished on or after the implementation date of the
prospective payment system under section 1834(o), under such
section (calculated as if `100 percent' were substituted for
`80 percent' in such section) for such services if the
individual had not been so enrolled'' after ``been so
enrolled''; and
(ii) by adding at the end the following flush sentence:
``Paragraph (3)(A) shall not apply to Federally qualified
health center services furnished on or after the
implementation date of the prospective payment system under
section 1834(0).''.
(j) Section 5505 is amended by adding at the end the
following new subsection:
``(d) Application.--The amendments made by this section
shall not be applied in a manner that requires reopening of
any settled cost reports as to which there is not a
jurisdictionally proper appeal pending as of the date of the
enactment of this Act on the issue of payment for indirect
costs of medical education under section 1886(d)(5)(B) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct
graduate medical education costs under section 1886(h) of
such Act (42 U.S.C. 1395ww(h)).''.
(k) Subtitle G of title V of this Act is amended by adding
at the end the following:
``SEC. 5606. STATE GRANTS TO HEALTH CARE PROVIDERS WHO
PROVIDE SERVICES TO A HIGH PERCENTAGE OF
MEDICALLY UNDERSERVED POPULATIONS OR OTHER
SPECIAL POPULATIONS.
``(a) In General.--A State may award grants to health care
providers who treat a high percentage, as determined by such
State, of medically underserved populations or other special
populations in such State.
``(b) Source of Funds.--A grant program established by a
State under subsection (a) may not be established within a
department, agency, or other entity of such State that
administers the Medicaid program under title XIX of the
Social Security Act (42 U.S.C. 1396 et seq.), and no Federal
or State funds allocated to such Medicaid program, the
Medicare program under title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.), or the TRICARE program under
chapter 55 of title 10, United States Code, may be used to
award grants or to pay administrative costs associated with a
grant program established under subsection (a).''.
(l) Part C of title VII of the Public Health Service Act
(42 U.S.C. 293k et seq.) is amended--
(1) after the part heading, by inserting the following:
``Subpart I--Medical Training Generally'';
and
(2) by inserting at the end the following:
``Subpart II--Training in Underserved Communities
``SEC. 749B. RURAL PHYSICIAN TRAINING GRANTS.
``(a) In General.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration, shall establish a grant program for the
purposes of assisting eligible entities in recruiting
students most likely to practice medicine in underserved
rural communities, providing rural-focused training and
experience, and increasing the number of recent allopathic
and osteopathic medical school graduates who practice in
underserved rural communities.
``(b) Eligible Entities.--In order to be eligible to
receive a grant under this section, an entity shall--
``(1) be a school of allopathic or osteopathic medicine
accredited by a nationally recognized accrediting agency or
association approved by the Secretary for this purpose, or
any combination or consortium of such schools; and
``(2) submit an application to the Secretary that includes
a certification that such entity will use amounts provided to
the institution as described in subsection (d)(1).
``(c) Priority.--In awarding grant funds under this
section, the Secretary shall give priority to eligible
entities that--
``(1) demonstrate a record of successfully training
students, as determined by the Secretary, who practice
medicine in underserved rural communities;
``(2) demonstrate that an existing academic program of the
eligible entity produces a high percentage, as determined by
the Secretary, of graduates from such program who practice
medicine in underserved rural communities;
``(3) demonstrate rural community institutional
partnerships, through such mechanisms as matching or
contributory funding, documented in-kind services for
implementation, or existence of training partners with
interprofessional expertise in community health center
training locations or other similar facilities; or
``(4) submit, as part of the application of the entity
under subsection (b), a plan for the long-term tracking of
where the graduates of such entity practice medicine.
``(d) Use of Funds.--
``(1) Establishment.--An eligible entity receiving a grant
under this section shall use the funds made available under
such grant to establish, improve, or expand a rural-focused
training program (referred to in this section as the
`Program') meeting the requirements described in this
subsection and to carry out such program.
``(2) Structure of program.--An eligible entity shall--
``(A) enroll no fewer than 10 students per class year into
the Program; and
``(B) develop criteria for admission to the Program that
gives priority to students--
``(i) who have originated from or lived for a period of 2
or more years in an underserved rural community; and
``(ii) who express a commitment to practice medicine in an
underserved rural community.
``(3) Curricula.--The Program shall require students to
enroll in didactic coursework and clinical experience
particularly applicable to medical practice in underserved
rural communities, including--
``(A) clinical rotations in underserved rural communities,
and in applicable specialties, or other coursework or
clinical experience deemed appropriate by the Secretary; and
``(B) in addition to core school curricula, additional
coursework or training experiences focused on medical issues
prevalent in underserved rural communities.
``(4) Residency placement assistance.--Where available, the
Program shall assist all students of the Program in obtaining
clinical training experiences in locations with postgraduate
programs offering residency training opportunities in
underserved rural communities, or in local residency training
programs that support and train physicians to practice in
underserved rural communities.
``(5) Program student cohort support.--The Program shall
provide and require all students of the Program to
participate in group activities designed to further develop,
maintain, and reinforce the original commitment of such
students to practice in an underserved rural community.
``(e) Annual Reporting.--An eligible entity receiving a
grant under this section shall submit an annual report to the
Secretary on the success of the Program, based on criteria
the Secretary determines appropriate, including the residency
program selection of graduating students who participated in
the Program.
``(f) Regulations.--Not later than 60 days after the date
of enactment of this section, the Secretary shall by
regulation define `underserved rural community' for purposes
of this section.
[[Page H2147]]
``(g) Supplement Not Supplant.--Any eligible entity
receiving funds under this section shall use such funds to
supplement, not supplant, any other Federal, State, and local
funds that would otherwise be expended by such entity to
carry out the activities described in this section.
``(h) Maintenance of Effort.--With respect to activities
for which funds awarded under this section are to be
expended, the entity shall agree to maintain expenditures of
non-Federal amounts for such activities at a level that is
not less than the level of such expenditures maintained by
the entity for the fiscal year preceding the fiscal year for
which the entity receives a grant under this section.
``(i) Authorization of Appropriations.--There are
authorized to be appropriated $4,000,000 for each of the
fiscal years 2010 through 2013.''.
(m)(1) Section 768 of the Public Health Service Act (42
U.S.C. 295c) is amended to read as follows:
``SEC. 768. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING
GRANT PROGRAM.
``(a) Grants.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration and in consultation with the Director of the
Centers for Disease Control and Prevention, shall award
grants to, or enter into contracts with, eligible entities to
provide training to graduate medical residents in preventive
medicine specialties.
``(b) Eligibility.--To be eligible for a grant or contract
under subsection (a), an entity shall be--
``(1) an accredited school of public health or school of
medicine or osteopathic medicine;
``(2) an accredited public or private nonprofit hospital;
``(3) a State, local, or tribal health department; or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(c) Use of Funds.--Amounts received under a grant or
contract under this section shall be used to--
``(1) plan, develop (including the development of
curricula), operate, or participate in an accredited
residency or internship program in preventive medicine or
public health;
``(2) defray the costs of practicum experiences, as
required in such a program; and
``(3) establish, maintain, or improve--
``(A) academic administrative units (including departments,
divisions, or other appropriate units) in preventive medicine
and public health; or
``(B) programs that improve clinical teaching in preventive
medicine and public health.
``(d) Report.--The Secretary shall submit to the Congress
an annual report on the program carried out under this
section.''.
(2) Section 770(a) of the Public Health Service Act (42
U.S.C. 295e(a)) is amended to read as follows:
``(a) In General.--For the purpose of carrying out this
subpart, there is authorized to be appropriated $43,000,000
for fiscal year 2011, and such sums as may be necessary for
each of the fiscal years 2012 through 2015.''.
(n)(1) Subsection (i) of section 331 of the Public Health
Service Act (42 U.S.C. 254d) of the Public Health Service Act
is amended--
(A) in paragraph (1), by striking ``In carrying out subpart
III'' and all that follows through the period and inserting
``In carrying out subpart III, the Secretary may, in
accordance with this subsection, issue waivers to individuals
who have entered into a contract for obligated service under
the Scholarship Program or the Loan Repayment Program under
which the individuals are authorized to satisfy the
requirement of obligated service through providing clinical
practice that is half time.'';
(B) in paragraph (2)--
(i) in subparagraphs (A)(ii) and (B), by striking ``less
than full time'' each place it appears and inserting ``half
time'';
(ii) in subparagraphs (C) and (F), by striking ``less than
full-time service'' each place it appears and inserting
``half-time service''; and
(iii) by amending subparagraphs (D) and (E) to read as
follows:
``(D) the entity and the Corps member agree in writing that
the Corps member will perform half-time clinical practice;
``(E) the Corps member agrees in writing to fulfill all of
the service obligations under section 338C through half-time
clinical practice and either--
``(i) double the period of obligated service that would
otherwise be required; or
``(ii) in the case of contracts entered into under section
338B, accept a minimum service obligation of 2 years with an
award amount equal to 50 percent of the amount that would
otherwise be payable for full-time service; and''; and
(C) in paragraph (3), by striking ``In evaluating a
demonstration project described in paragraph (1)'' and
inserting ``In evaluating waivers issued under paragraph
(1)''.
(2) Subsection (j) of section 331 of the Public Health
Service Act (42 U.S.C. 254d) is amended by adding at the end
the following:
``(5) The terms `full time' and `full-time' mean a minimum
of 40 hours per week in a clinical practice, for a minimum of
45 weeks per year.
``(6) The terms `half time' and `half-time' mean a minimum
of 20 hours per week (not to exceed 39 hours per week) in a
clinical practice, for a minimum of 45 weeks per year.''.
(3) Section 337(b)(1) of the Public Health Service Act (42
U.S.C. 254j(b)(1)) is amended by striking ``Members may not
be reappointed to the Council.''.
(4) Section 338B(g)(2)(A) of the Public Health Service Act
(42 U.S.C. 254l-1(g)(2)(A)) is amended by striking
``$35,000'' and inserting ``$50,000, plus, beginning with
fiscal year 2012, an amount determined by the Secretary on an
annual basis to reflect inflation,''.
(5) Subsection (a) of section 338C of the Public Health
Service Act (42 U.S.C. 254m), as amended by section 5508, is
amended--
(A) by striking the second sentence and inserting the
following: ``The Secretary may treat teaching as clinical
practice for up to 20 percent of such period of obligated
service.''; and
(B) by adding at the end the following: ``Notwithstanding
the preceding sentence, with respect to a member of the Corps
participating in the teaching health centers graduate medical
education program under section 340H, for the purpose of
calculating time spent in full-time clinical practice under
this section, up to 50 percent of time spent teaching by such
member may be counted toward his or her service
obligation.''.
SEC. 10502. INFRASTRUCTURE TO EXPAND ACCESS TO CARE.
(a) Appropriation.--There are authorized to be
appropriated, and there are appropriated to the Department of
Health and Human Services, $100,000,000 for fiscal year 2010,
to remain available for obligation until September 30, 2011,
to be used for debt service on, or direct construction or
renovation of, a health care facility that provides research,
inpatient tertiary care, or outpatient clinical services.
Such facility shall be affiliated with an academic health
center at a public research university in the United States
that contains a State's sole public academic medical and
dental school.
(b) Requirement.--Amount appropriated under subsection (a)
may only be made available by the Secretary of Health and
Human Services upon the receipt of an application from the
Governor of a State that certifies that--
(1) the new health care facility is critical for the
provision of greater access to health care within the State;
(2) such facility is essential for the continued financial
viability of the State's sole public medical and dental
school and its academic health center;
(3) the request for Federal support represents not more
than 40 percent of the total cost of the proposed new
facility; and
(4) the State has established a dedicated funding mechanism
to provide all remaining funds necessary to complete the
construction or renovation of the proposed facility.
SEC. 10503. COMMUNITY HEALTH CENTERS AND THE NATIONAL HEALTH
SERVICE CORPS FUND.
(a) Purpose.--It is the purpose of this section to
establish a Community Health Center Fund (referred to in this
section as the ``CHC Fund''), to be administered through the
Office of the Secretary of the Department of Health and Human
Services to provide for expanded and sustained national
investment in community health centers under section 330 of
the Public Health Service Act and the National Health Service
Corps.
(b) Funding.--There is authorized to be appropriated, and
there is appropriated, out of any monies in the Treasury not
otherwise appropriated, to the CHC Fund--
(1) to be transferred to the Secretary of Health and Human
Services to provide enhanced funding for the community health
center program under section 330 of the Public Health Service
Act--
(A) $700,000,000 for fiscal year 2011;
(B) $800,000,000 for fiscal year 2012;
(C) $1,000,000,000 for fiscal year 2013;
(D) $1,600,000,000 for fiscal year 2014; and
(E) $2,900,000,000 for fiscal year 2015; and
(2) to be transferred to the Secretary of Health and Human
Services to provide enhanced funding for the National Health
Service Corps--
(A) $290,000,000 for fiscal year 2011;
(B) $295,000,000 for fiscal year 2012;
(C) $300,000,000 for fiscal year 2013;
(D) $305,000,000 for fiscal year 2014; and
(E) $310,000,000 for fiscal year 2015.
(c) Construction.--There is authorized to be appropriated,
and there is appropriated, out of any monies in the Treasury
not otherwise appropriated, $1,500,000,000 to be available
for fiscal years 2011 through 2015 to be used by the
Secretary of Health and Human Services for the construction
and renovation of community health centers.
(d) Use of Fund.--The Secretary of Health and Human
Services shall transfer amounts in the CHC Fund to accounts
within the Department of Health and Human Services to
increase funding, over the fiscal year 2008 level, for
community health centers and the National Health Service
Corps.
(e) Availability.--Amounts appropriated under subsections
(b) and (c) shall remain available until expended.
SEC. 10504. DEMONSTRATION PROJECT TO PROVIDE ACCESS TO
AFFORDABLE CARE.
(a) In General.--Not later than 6 months after the date of
enactment of this Act, the Secretary of Health and Human
Services (referred to in this section as the ``Secretary''),
acting through the Health Resources and Services
Administration, shall establish a 3 year demonstration
project in up to 10 States to provide access to comprehensive
health care services to the uninsured at reduced fees. The
Secretary shall evaluate the feasibility of expanding the
project to additional States.
(b) Eligibility.--To be eligible to participate in the
demonstration project, an entity shall be a State-based,
nonprofit, public-private partnership that provides access to
comprehensive health care services to the uninsured at
reduced fees. Each State in which a participant selected by
the Secretary is located shall receive not more than
$2,000,000 to establish and carry out the project for the 3-
year demonstration period.
(c) Authorization.--There is authorized to be appropriated
such sums as may be necessary to carry out this section.
[[Page H2148]]
Subtitle F--Provisions Relating to Title VI
SEC. 10601. REVISIONS TO LIMITATION ON MEDICARE EXCEPTION TO
THE PROHIBITION ON CERTAIN PHYSICIAN REFERRALS
FOR HOSPITALS.
(a) In General.--Section 1877(i) of the Social Security
Act, as added by section 6001(a), is amended--
(1) in paragraph (1)(A)(i), by striking ``February 1,
2010'' and inserting ``August 1, 2010''; and
(2) in paragraph (3)(A)--
(A) in clause (iii), by striking ``August 1, 2011'' and
inserting ``February 1, 2012''; and
(B) in clause (iv), by striking ``July 1, 2011'' and
inserting ``January 1, 2012''.
(b) Conforming Amendment.--Section 6001(b)(2) of this Act
is amended by striking ``November 1, 2011'' and inserting
``May 1, 2012''.
SEC. 10602. CLARIFICATIONS TO PATIENT-CENTERED OUTCOMES
RESEARCH.
Section 1181 of the Social Security Act (as added by
section 6301) is amended--
(1) in subsection (d)(2)(B)--
(A) in clause (ii)(IV)--
(i) by inserting ``, as described in subparagraph
(A)(ii),'' after ``original research''; and
(ii) by inserting ``, as long as the researcher enters into
a data use agreement with the Institute for use of the data
from the original research, as appropriate'' after
``publication''; and
(B) by amending clause (iv) to read as follows:
``(iv) Subsequent use of the data.--The Institute shall not
allow the subsequent use of data from original research in
work-for-hire contracts with individuals, entities, or
instrumentalities that have a financial interest in the
results, unless approved under a data use agreement with the
Institute.'';
(2) in subsection (d)(8)(A)(iv), by striking ``not be
construed as mandates for'' and inserting ``do not include'';
and
(3) in subsection (f)(1)(C), by amending clause (ii) to
read as follows:
``(ii) 7 members representing physicians and providers,
including 4 members representing physicians (at least 1 of
whom is a surgeon), 1 nurse, 1 State-licensed integrative
health care practitioner, and 1 representative of a
hospital.''.
SEC. 10603. STRIKING PROVISIONS RELATING TO INDIVIDUAL
PROVIDER APPLICATION FEES.
(a) In General.--Section 1866(j)(2)(C) of the Social
Security Act, as added by section 6401(a), is amended--
(1) by striking clause (i);
(2) by redesignating clauses (ii) through (iv),
respectively, as clauses (i) through (iii); and
(3) in clause (i), as redesignated by paragraph (2), by
striking ``clause (iii)'' and inserting ``clause (ii)''.
(b) Technical Correction.--Section 6401(a)(2) of this Act
is amended to read as follows:
``(2) by redesignating paragraph (2) as paragraph (8);
and''.
SEC. 10604. TECHNICAL CORRECTION TO SECTION 6405.
Paragraphs (1) and (2) of section 6405(b) are amended to
read as follows:
``(1) Part a.--Section 1814(a)(2) of the Social Security
Act (42 U.S.C. 1395(a)(2)) is amended in the matter preceding
subparagraph (A) by inserting `, or, in the case of services
described in subparagraph (C), a physician enrolled under
section 1866(j),' after `in collaboration with a physician,'.
``(2) Part b.--Section 1835(a)(2) of the Social Security
Act (42 U.S.C. 1395n(a)(2)) is amended in the matter
preceding subparagraph (A) by inserting `, or, in the case of
services described in subparagraph (A), a physician enrolled
under section 1866(j),' after `a physician'.''.
SEC. 10605. CERTAIN OTHER PROVIDERS PERMITTED TO CONDUCT FACE
TO FACE ENCOUNTER FOR HOME HEALTH SERVICES.
(a) Part A.--Section 1814(a)(2)(C) of the Social Security
Act (42 U.S.C. 1395f(a)(2)(C)), as amended by section
6407(a)(1), is amended by inserting ``, or a nurse
practitioner or clinical nurse specialist (as those terms are
defined in section 1861(aa)(5)) who is working in
collaboration with the physician in accordance with State
law, or a certified nurse-midwife (as defined in section
1861(gg)) as authorized by State law, or a physician
assistant (as defined in section 1861(aa)(5)) under the
supervision of the physician,'' after ``himself or herself''.
(b) Part B.--Section 1835(a)(2)(A)(iv) of the Social
Security Act, as added by section 6407(a)(2), is amended by
inserting ``, or a nurse practitioner or clinical nurse
specialist (as those terms are defined in section
1861(aa)(5)) who is working in collaboration with the
physician in accordance with State law, or a certified nurse-
midwife (as defined in section 1861(gg)) as authorized by
State law, or a physician assistant (as defined in section
1861(aa)(5)) under the supervision of the physician,'' after
``must document that the physician''.
SEC. 10606. HEALTH CARE FRAUD ENFORCEMENT.
(a) Fraud Sentencing Guidelines.--
(1) Definition.--In this subsection, the term ``Federal
health care offense'' has the meaning given that term in
section 24 of title 18, United States Code, as amended by
this Act.
(2) Review and amendments.--Pursuant to the authority under
section 994 of title 28, United States Code, and in
accordance with this subsection, the United States Sentencing
Commission shall--
(A) review the Federal Sentencing Guidelines and policy
statements applicable to persons convicted of Federal health
care offenses;
(B) amend the Federal Sentencing Guidelines and policy
statements applicable to persons convicted of Federal health
care offenses involving Government health care programs to
provide that the aggregate dollar amount of fraudulent bills
submitted to the Government health care program shall
constitute prima facie evidence of the amount of the intended
loss by the defendant; and
(C) amend the Federal Sentencing Guidelines to provide--
(i) a 2-level increase in the offense level for any
defendant convicted of a Federal health care offense relating
to a Government health care program which involves a loss of
not less than $1,000,000 and less than $7,000,000;
(ii) a 3-level increase in the offense level for any
defendant convicted of a Federal health care offense relating
to a Government health care program which involves a loss of
not less than $7,000,000 and less than $20,000,000;
(iii) a 4-level increase in the offense level for any
defendant convicted of a Federal health care offense relating
to a Government health care program which involves a loss of
not less than $20,000,000; and
(iv) if appropriate, otherwise amend the Federal Sentencing
Guidelines and policy statements applicable to persons
convicted of Federal health care offenses involving
Government health care programs.
(3) Requirements.--In carrying this subsection, the United
States Sentencing Commission shall--
(A) ensure that the Federal Sentencing Guidelines and
policy statements--
(i) reflect the serious harms associated with health care
fraud and the need for aggressive and appropriate law
enforcement action to prevent such fraud; and
(ii) provide increased penalties for persons convicted of
health care fraud offenses in appropriate circumstances;
(B) consult with individuals or groups representing health
care fraud victims, law enforcement officials, the health
care industry, and the Federal judiciary as part of the
review described in paragraph (2);
(C) ensure reasonable consistency with other relevant
directives and with other guidelines under the Federal
Sentencing Guidelines;
(D) account for any aggravating or mitigating circumstances
that might justify exceptions, including circumstances for
which the Federal Sentencing Guidelines, as in effect on the
date of enactment of this Act, provide sentencing
enhancements;
(E) make any necessary conforming changes to the Federal
Sentencing Guidelines; and
(F) ensure that the Federal Sentencing Guidelines
adequately meet the purposes of sentencing.
(b) Intent Requirement for Health Care Fraud.--Section 1347
of title 18, United States Code, is amended--
(1) by inserting ``(a)'' before ``Whoever knowingly''; and
(2) by adding at the end the following:
``(b) With respect to violations of this section, a person
need not have actual knowledge of this section or specific
intent to commit a violation of this section.''.
(c) Health Care Fraud Offense.--Section 24(a) of title 18,
United States Code, is amended--
(1) in paragraph (1), by striking the semicolon and
inserting ``or section 1128B of the Social Security Act (42
U.S.C. 1320a-7b); or''; and
(2) in paragraph (2)--
(A) by inserting ``1349,'' after ``1343,''; and
(B) by inserting ``section 301 of the Federal Food, Drug,
and Cosmetic Act (21 U.S.C. 331), or section 501 of the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
1131),'' after ``title,''.
(d) Subpoena Authority Relating to Health Care.--
(1) Subpoenas under the health insurance portability and
accountability act of 1996.--Section 1510(b) of title 18,
United States Code, is amended--
(A) in paragraph (1), by striking ``to the grand jury'';
and
(B) in paragraph (2)--
(i) in subparagraph (A), by striking ``grand jury
subpoena'' and inserting ``subpoena for records''; and
(ii) in the matter following subparagraph (B), by striking
``to the grand jury''.
(2) Subpoenas under the civil rights of institutionalized
persons act.--The Civil Rights of Institutionalized Persons
Act (42 U.S.C. 1997 et seq.) is amended by inserting after
section 3 the following:
``SEC. 3A. SUBPOENA AUTHORITY.
``(a) Authority.--The Attorney General, or at the direction
of the Attorney General, any officer or employee of the
Department of Justice may require by subpoena access to any
institution that is the subject of an investigation under
this Act and to any document, record, material, file, report,
memorandum, policy, procedure, investigation, video or audio
recording, or quality assurance report relating to any
institution that is the subject of an investigation under
this Act to determine whether there are conditions which
deprive persons residing in or confined to the institution of
any rights, privileges, or immunities secured or protected by
the Constitution or laws of the United States.
``(b) Issuance and Enforcement of Subpoenas.--
``(1) Issuance.--Subpoenas issued under this section--
``(A) shall bear the signature of the Attorney General or
any officer or employee of the Department of Justice as
designated by the Attorney General; and
``(B) shall be served by any person or class of persons
designated by the Attorney General or a designated officer or
employee for that purpose.
[[Page H2149]]
``(2) Enforcement.--In the case of contumacy or failure to
obey a subpoena issued under this section, the United States
district court for the judicial district in which the
institution is located may issue an order requiring
compliance. Any failure to obey the order of the court may be
punished by the court as a contempt that court.
``(c) Protection of Subpoenaed Records and Information.--
Any document, record, material, file, report, memorandum,
policy, procedure, investigation, video or audio recording,
or quality assurance report or other information obtained
under a subpoena issued under this section--
``(1) may not be used for any purpose other than to protect
the rights, privileges, or immunities secured or protected by
the Constitution or laws of the United States of persons who
reside, have resided, or will reside in an institution;
``(2) may not be transmitted by or within the Department of
Justice for any purpose other than to protect the rights,
privileges, or immunities secured or protected by the
Constitution or laws of the United States of persons who
reside, have resided, or will reside in an institution; and
``(3) shall be redacted, obscured, or otherwise altered if
used in any publicly available manner so as to prevent the
disclosure of any personally identifiable information.''.
SEC. 10607. STATE DEMONSTRATION PROGRAMS TO EVALUATE
ALTERNATIVES TO CURRENT MEDICAL TORT
LITIGATION.
Part P of title III of the Public Health Service Act (42
U.S.C. 280g et seq.), as amended by this Act, is further
amended by adding at the end the following:
``SEC. 399V-4. STATE DEMONSTRATION PROGRAMS TO EVALUATE
ALTERNATIVES TO CURRENT MEDICAL TORT
LITIGATION.
``(a) In General.--The Secretary is authorized to award
demonstration grants to States for the development,
implementation, and evaluation of alternatives to current
tort litigation for resolving disputes over injuries
allegedly caused by health care providers or health care
organizations. In awarding such grants, the Secretary shall
ensure the diversity of the alternatives so funded.
``(b) Duration.--The Secretary may award grants under
subsection (a) for a period not to exceed 5 years.
``(c) Conditions for Demonstration Grants.--
``(1) Requirements.--Each State desiring a grant under
subsection (a) shall develop an alternative to current tort
litigation that--
``(A) allows for the resolution of disputes over injuries
allegedly caused by health care providers or health care
organizations; and
``(B) promotes a reduction of health care errors by
encouraging the collection and analysis of patient safety
data related to disputes resolved under subparagraph (A) by
organizations that engage in efforts to improve patient
safety and the quality of health care.
``(2) Alternative to current tort litigation.--Each State
desiring a grant under subsection (a) shall demonstrate how
the proposed alternative described in paragraph (1)(A)--
``(A) makes the medical liability system more reliable by
increasing the availability of prompt and fair resolution of
disputes;
``(B) encourages the efficient resolution of disputes;
``(C) encourages the disclosure of health care errors;
``(D) enhances patient safety by detecting, analyzing, and
helping to reduce medical errors and adverse events;
``(E) improves access to liability insurance;
``(F) fully informs patients about the differences in the
alternative and current tort litigation;
``(G) provides patients the ability to opt out of or
voluntarily withdraw from participating in the alternative at
any time and to pursue other options, including litigation,
outside the alternative;
``(H) would not conflict with State law at the time of the
application in a way that would prohibit the adoption of an
alternative to current tort litigation; and
``(I) would not limit or curtail a patient's existing legal
rights, ability to file a claim in or access a State's legal
system, or otherwise abrogate a patient's ability to file a
medical malpractice claim.
``(3) Sources of compensation.--Each State desiring a grant
under subsection (a) shall identify the sources from and
methods by which compensation would be paid for claims
resolved under the proposed alternative to current tort
litigation, which may include public or private funding
sources, or a combination of such sources. Funding methods
shall to the extent practicable provide financial incentives
for activities that improve patient safety.
``(4) Scope.--
``(A) In general.--Each State desiring a grant under
subsection (a) shall establish a scope of jurisdiction (such
as Statewide, designated geographic region, a designated area
of health care practice, or a designated group of health care
providers or health care organizations) for the proposed
alternative to current tort litigation that is sufficient to
evaluate the effects of the alternative. No scope of
jurisdiction shall be established under this paragraph that
is based on a health care payer or patient population.
``(B) Notification of patients.--A State shall demonstrate
how patients would be notified that they are receiving health
care services that fall within such scope, and the process by
which they may opt out of or voluntarily withdraw from
participating in the alternative. The decision of the patient
whether to participate or continue participating in the
alternative process shall be made at any time and shall not
be limited in any way.
``(5) Preference in awarding demonstration grants.--In
awarding grants under subsection (a), the Secretary shall
give preference to States--
``(A) that have developed the proposed alternative through
substantive consultation with relevant stakeholders,
including patient advocates, health care providers and health
care organizations, attorneys with expertise in representing
patients and health care providers, medical malpractice
insurers, and patient safety experts;
``(B) that make proposals that are likely to enhance
patient safety by detecting, analyzing, and helping to reduce
medical errors and adverse events; and
``(C) that make proposals that are likely to improve access
to liability insurance.
``(d) Application.--
``(1) In general.--Each State desiring a grant under
subsection (a) shall submit to the Secretary an application,
at such time, in such manner, and containing such information
as the Secretary may require.
``(2) Review panel.--
``(A) In general.--In reviewing applications under
paragraph (1), the Secretary shall consult with a review
panel composed of relevant experts appointed by the
Comptroller General.
``(B) Composition.--
``(i) Nominations.--The Comptroller General shall solicit
nominations from the public for individuals to serve on the
review panel.
``(ii) Appointment.--The Comptroller General shall appoint,
at least 9 but not more than 13, highly qualified and
knowledgeable individuals to serve on the review panel and
shall ensure that the following entities receive fair
representation on such panel:
``(I) Patient advocates.
``(II) Health care providers and health care organizations.
``(III) Attorneys with expertise in representing patients
and health care providers.
``(IV) Medical malpractice insurers.
``(V) State officials.
``(VI) Patient safety experts.
``(C) Chairperson.--The Comptroller General, or an
individual within the Government Accountability Office
designated by the Comptroller General, shall be the
chairperson of the review panel.
``(D) Availability of information.--The Comptroller General
shall make available to the review panel such information,
personnel, and administrative services and assistance as the
review panel may reasonably require to carry out its duties.
``(E) Information from agencies.--The review panel may
request directly from any department or agency of the United
States any information that such panel considers necessary to
carry out its duties. To the extent consistent with
applicable laws and regulations, the head of such department
or agency shall furnish the requested information to the
review panel.
``(e) Reports.--
``(1) By state.--Each State receiving a grant under
subsection (a) shall submit to the Secretary an annual report
evaluating the effectiveness of activities funded with grants
awarded under such subsection. Such report shall, at a
minimum, include the impact of the activities funded on
patient safety and on the availability and price of medical
liability insurance.
``(2) By secretary.--The Secretary shall submit to Congress
an annual compendium of the reports submitted under paragraph
(1) and an analysis of the activities funded under subsection
(a) that examines any differences that result from such
activities in terms of the quality of care, number and nature
of medical errors, medical resources used, length of time for
dispute resolution, and the availability and price of
liability insurance.
``(f) Technical Assistance.--
``(1) In general.--The Secretary shall provide technical
assistance to the States applying for or awarded grants under
subsection (a).
``(2) Requirements.--Technical assistance under paragraph
(1) shall include--
``(A) guidance on non-economic damages, including the
consideration of individual facts and circumstances in
determining appropriate payment, guidance on identifying
avoidable injuries, and guidance on disclosure to patients of
health care errors and adverse events; and
``(B) the development, in consultation with States, of
common definitions, formats, and data collection
infrastructure for States receiving grants under this section
to use in reporting to facilitate aggregation and analysis of
data both within and between States.
``(3) Use of common definitions, formats, and data
collection infrastructure.--States not receiving grants under
this section may also use the common definitions, formats,
and data collection infrastructure developed under paragraph
(2)(B).
``(g) Evaluation.--
``(1) In general.--The Secretary, in consultation with the
review panel established under subsection (d)(2), shall enter
into a contract with an appropriate research organization to
conduct an overall evaluation of the effectiveness of grants
awarded under subsection (a) and to annually prepare and
submit a report to Congress. Such an evaluation shall begin
not later than 18 months following the date of implementation
of the first program funded by a grant under subsection (a).
``(2) Contents.--The evaluation under paragraph (1) shall
include--
``(A) an analysis of the effects of the grants awarded
under subsection (a) with regard to the measures described in
paragraph (3);
``(B) for each State, an analysis of the extent to which
the alternative developed under subsection (c)(1) is
effective in meeting the elements described in subsection
(c)(2);
``(C) a comparison among the States receiving grants under
subsection (a) of the effectiveness
[[Page H2150]]
of the various alternatives developed by such States under
subsection (c)(1);
``(D) a comparison, considering the measures described in
paragraph (3), of States receiving grants approved under
subsection (a) and similar States not receiving such grants;
and
``(E) a comparison, with regard to the measures described
in paragraph (3), of--
``(i) States receiving grants under subsection (a);
``(ii) States that enacted, prior to the date of enactment
of the Patient Protection and Affordable Care Act, any cap on
non-economic damages; and
``(iii) States that have enacted, prior to the date of
enactment of the Patient Protection and Affordable Care Act,
a requirement that the complainant obtain an opinion
regarding the merit of the claim, although the substance of
such opinion may have no bearing on whether the complainant
may proceed with a case.
``(3) Measures.--The evaluations under paragraph (2) shall
analyze and make comparisons on the basis of--
``(A) the nature and number of disputes over injuries
allegedly caused by health care providers or health care
organizations;
``(B) the nature and number of claims in which tort
litigation was pursued despite the existence of an
alternative under subsection (a);
``(C) the disposition of disputes and claims, including the
length of time and estimated costs to all parties;
``(D) the medical liability environment;
``(E) health care quality;
``(F) patient safety in terms of detecting, analyzing, and
helping to reduce medical errors and adverse events;
``(G) patient and health care provider and organization
satisfaction with the alternative under subsection (a) and
with the medical liability environment; and
``(H) impact on utilization of medical services,
appropriately adjusted for risk.
``(4) Funding.--The Secretary shall reserve 5 percent of
the amount appropriated in each fiscal year under subsection
(k) to carry out this subsection.
``(h) MedPAC and MACPAC Reports.--
``(1) MedPAC.--The Medicare Payment Advisory Commission
shall conduct an independent review of the alternatives to
current tort litigation that are implemented under grants
under subsection (a) to determine the impact of such
alternatives on the Medicare program under title XVIII of the
Social Security Act, and its beneficiaries.
``(2) MACPAC.--The Medicaid and CHIP Payment and Access
Commission shall conduct an independent review of the
alternatives to current tort litigation that are implemented
under grants under subsection (a) to determine the impact of
such alternatives on the Medicaid or CHIP programs under
titles XIX and XXI of the Social Security Act, and their
beneficiaries.
``(3) Reports.--Not later than December 31, 2016, the
Medicare Payment Advisory Commission and the Medicaid and
CHIP Payment and Access Commission shall each submit to
Congress a report that includes the findings and
recommendations of each respective Commission based on
independent reviews conducted under paragraphs (1) and (2),
including an analysis of the impact of the alternatives
reviewed on the efficiency and effectiveness of the
respective programs.
``(i) Option To Provide for Initial Planning Grants.--Of
the funds appropriated pursuant to subsection (k), the
Secretary may use a portion not to exceed $500,000 per State
to provide planning grants to such States for the development
of demonstration project applications meeting the criteria
described in subsection (c). In selecting States to receive
such planning grants, the Secretary shall give preference to
those States in which State law at the time of the
application would not prohibit the adoption of an alternative
to current tort litigation.
``(j) Definitions.--In this section:
``(1) Health care services.--The term `health care
services' means any services provided by a health care
provider, or by any individual working under the supervision
of a health care provider, that relate to--
``(A) the diagnosis, prevention, or treatment of any human
disease or impairment; or
``(B) the assessment of the health of human beings.
``(2) Health care organization.--The term `health care
organization' means any individual or entity which is
obligated to provide, pay for, or administer health benefits
under any health plan.
``(3) Health care provider.--The term `health care
provider' means any individual or entity--
``(A) licensed, registered, or certified under Federal or
State laws or regulations to provide health care services; or
``(B) required to be so licensed, registered, or certified
but that is exempted by other statute or regulation.
``(k) Authorization of Appropriations.--There are
authorized to be appropriated to carry out this section,
$50,000,000 for the 5-fiscal year period beginning with
fiscal year 2011.
``(l) Current State Efforts To Establish Alternative To
Tort Litigation.--Nothing in this section shall be construed
to limit any prior, current, or future efforts of any State
to establish any alternative to tort litigation.
``(m) Rule of Construction.--Nothing in this section shall
be construed as limiting states' authority over or
responsibility for their state justice systems.''.
SEC. 10608. EXTENSION OF MEDICAL MALPRACTICE COVERAGE TO FREE
CLINICS.
(a) In General.--Section 224(o)(1) of the Public Health
Service Act (42 U.S.C. 233(o)(1)) is amended by inserting
after ``to an individual'' the following: ``, or an officer,
governing board member, employee, or contractor of a free
clinic shall in providing services for the free clinic,''.
(b) Effective Date.--The amendment made by this section
shall take effect on the date of enactment of this Act and
apply to any act or omission which occurs on or after that
date.
SEC. 10609. LABELING CHANGES.
Section 505(j) of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. 355(j)) is amended by adding at the end the
following:
``(10)(A) If the proposed labeling of a drug that is the
subject of an application under this subsection differs from
the listed drug due to a labeling revision described under
clause (i), the drug that is the subject of such application
shall, notwithstanding any other provision of this Act, be
eligible for approval and shall not be considered misbranded
under section 502 if--
``(i) the application is otherwise eligible for approval
under this subsection but for expiration of patent, an
exclusivity period, or of a delay in approval described in
paragraph (5)(B)(iii), and a revision to the labeling of the
listed drug has been approved by the Secretary within 60 days
of such expiration;
``(ii) the labeling revision described under clause (i)
does not include a change to the `Warnings' section of the
labeling;
``(iii) the sponsor of the application under this
subsection agrees to submit revised labeling of the drug that
is the subject of such application not later than 60 days
after the notification of any changes to such labeling
required by the Secretary; and
``(iv) such application otherwise meets the applicable
requirements for approval under this subsection.
``(B) If, after a labeling revision described in
subparagraph (A)(i), the Secretary determines that the
continued presence in interstate commerce of the labeling of
the listed drug (as in effect before the revision described
in subparagraph (A)(i)) adversely impacts the safe use of the
drug, no application under this subsection shall be eligible
for approval with such labeling.''.
Subtitle G--Provisions Relating to Title VIII
SEC. 10801. PROVISIONS RELATING TO TITLE VIII.
(a) Title XXXII of the Public Health Service Act, as added
by section 8002(a)(1), is amended--
(1) in section 3203--
(A) in subsection (a)(1), by striking subparagraph (E);
(B) in subsection (b)(1)(C)(i), by striking ``for
enrollment'' and inserting ``for reenrollment''; and
(C) in subsection (c)(1), by striking ``, as part of their
automatic enrollment in the CLASS program,''; and
(2) in section 3204--
(A) in subsection (c)(2), by striking subparagraph (A) and
inserting the following:
``(A) receives wages or income on which there is imposed a
tax under section 3101(a) or 3201(a) of the Internal Revenue
Code of 1986; or'';
(B) in subsection (d), by striking ``subparagraph (B) or
(C) of subsection (c)(1)'' and inserting ``subparagraph (A)
or (B) of subsection (c)(2)'';
(C) in subsection (e)(2)(A), by striking ``subparagraph
(A)'' and inserting ``paragraph (1)''; and
(D) in subsection (g)(1), by striking ``has elected to
waive enrollment'' and inserting ``has not enrolled''.
(b) Section 8002 of this Act is amended in the heading for
subsection (d), by striking ``Information on Supplemental
Coverage'' and inserting ``CLASS Program Information''.
(c) Section 6021(d)(2)(A)(iv) of the Deficit Reduction Act
of 2005, as added by section 8002(d) of this Act, is amended
by striking ``and coverage available'' and all that follows
through ``that program,''.
Subtitle H--Provisions Relating to Title IX
SEC. 10901. MODIFICATIONS TO EXCISE TAX ON HIGH COST
EMPLOYER-SPONSORED HEALTH COVERAGE.
(a) Longshore Workers Treated as Employees Engaged in High-
risk Professions.--Paragraph (3) of section 4980I(f) of the
Internal Revenue Code of 1986, as added by section 9001 of
this Act, is amended by inserting ``individuals whose primary
work is longshore work (as defined in section 258(b) of the
Immigration and Nationality Act (8 U.S.C. 1288(b)),
determined without regard to paragraph (2) thereof),'' before
``and individuals engaged in the construction, mining''.
(b) Exemption From High-cost Insurance Tax Includes Certain
Additional Excepted Benefits.--Clause (i) of section
4980I(d)(1)(B) of the Internal Revenue Code of 1986, as added
by section 9001 of this Act, is amended by striking ``section
9832(c)(1)(A)'' and inserting ``section 9832(c)(1) (other
than subparagraph (G) thereof)''.
(c) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2012.
SEC. 10902. INFLATION ADJUSTMENT OF LIMITATION ON HEALTH
FLEXIBLE SPENDING ARRANGEMENTS UNDER CAFETERIA
PLANS.
(a) In General.--Subsection (i) of section 125 of the
Internal Revenue Code of 1986, as added by section 9005 of
this Act, is amended to read as follows:
``(i) Limitation on Health Flexible Spending
Arrangements.--
``(1) In general.--For purposes of this section, if a
benefit is provided under a cafeteria plan through employer
contributions to a health flexible spending arrangement, such
benefit shall not be treated as a qualified benefit unless
the cafeteria plan provides that an employee may not elect
for any taxable year to have salary reduction contributions
in excess of $2,500 made to such arrangement.
[[Page H2151]]
``(2) Adjustment for inflation.--In the case of any taxable
year beginning after December 31, 2011, the dollar amount in
paragraph (1) shall be increased by an amount equal to--
``(A) such amount, multiplied by
``(B) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year in which such taxable
year begins by substituting `calendar year 2010' for
`calendar year 1992' in subparagraph (B) thereof.
If any increase determined under this paragraph is not a
multiple of $50, such increase shall be rounded to the next
lowest multiple of $50.''.
(b) Effective Date.--The amendment made by this section
shall apply to taxable years beginning after December 31,
2010.
SEC. 10903. MODIFICATION OF LIMITATION ON CHARGES BY
CHARITABLE HOSPITALS.
(a) In General.--Subparagraph (A) of section 501(r)(5) of
the Internal Revenue Code of 1986, as added by section 9007
of this Act, is amended by striking ``the lowest amounts
charged'' and inserting ``the amounts generally billed''.
(b) Effective Date.--The amendment made by this section
shall apply to taxable years beginning after the date of the
enactment of this Act.
SEC. 10904. MODIFICATION OF ANNUAL FEE ON MEDICAL DEVICE
MANUFACTURERS AND IMPORTERS.
(a) In General.--Section 9009 of this Act is amended--
(1) by striking ``2009'' in subsection (a)(1) and inserting
``2010'',
(2) by inserting ``($3,000,000,000 after 2017)'' after
``$2,000,000,000'', and
(3) by striking ``2008'' in subsection (i) and inserting
``2009''.
(b) Effective Date.--The amendments made by this section
shall take effect as if included in the enactment of section
9009.
SEC. 10905. MODIFICATION OF ANNUAL FEE ON HEALTH INSURANCE
PROVIDERS.
(a) Determination of Fee Amount.--Subsection (b) of section
9010 of this Act is amended to read as follows:
``(b) Determination of Fee Amount.--
``(1) In general.--With respect to each covered entity, the
fee under this section for any calendar year shall be equal
to an amount that bears the same ratio to the applicable
amount as--
``(A) the covered entity's net premiums written with
respect to health insurance for any United States health risk
that are taken into account during the preceding calendar
year, bears to
``(B) the aggregate net premiums written with respect to
such health insurance of all covered entities that are taken
into account during such preceding calendar year.
``(2) Amounts taken into account.--For purposes of
paragraph (1), the net premiums written with respect to
health insurance for any United States health risk that are
taken into account during any calendar year with respect to
any covered entity shall be determined in accordance with the
following table:
``With respect to a covered entity's The percentage of net premiums
net premiums written during the written that are taken into
calendar year that are: account is:
Not more than $25,000,000............ 0 percent
More than $25,000,000 but not more 50 percent
than $50,000,000.
More than $50,000,000................ 100 percent.
``(3) Secretarial determination.--The Secretary shall
calculate the amount of each covered entity's fee for any
calendar year under paragraph (1). In calculating such
amount, the Secretary shall determine such covered entity's
net premiums written with respect to any United States health
risk on the basis of reports submitted by the covered entity
under subsection (g) and through the use of any other source
of information available to the Secretary.''.
(b) Applicable Amount.--Subsection (e) of section 9010 of
this Act is amended to read as follows:
``(e) Applicable Amount.--For purposes of subsection
(b)(1), the applicable amount shall be determined in
accordance with the following table:
``Calendar year Applicable amount
2011.................................... $2,000,000,000
2012.................................... $4,000,000,000
2013.................................... $7,000,000,000
2014, 2015 and 2016..................... $9,000,000,000
2017 and thereafter..................... $10,000,000,000.''.
(c) Exemption From Annual Fee on Health Insurance for
Certain Nonprofit Entities.--Section 9010(c)(2) of this Act
is amended by striking ``or'' at the end of subparagraph (A),
by striking the period at the end of subparagraph (B) and
inserting a comma, and by adding at the end the following new
subparagraphs:
``(C) any entity--
``(i)(I) which is incorporated as, is a wholly owned
subsidiary of, or is a wholly owned affiliate of, a nonprofit
corporation under a State law, or
``(II) which is described in section 501(c)(4) of the
Internal Revenue Code of 1986 and the activities of which
consist of providing commercial-type insurance (within the
meaning of section 501(m) of such Code),
``(ii) the premium rate increases of which are regulated by
a State authority,
``(iii) which, as of the date of the enactment of this
section, acts as the insurer of last resort in the State and
is subject to State guarantee issue requirements, and
``(iv) for which the medical loss ratio (determined in a
manner consistent with the determination of such ratio under
section 2718(b)(1)(A) of the Public Health Service Act) with
respect to the individual insurance market for such entity
for the calendar year is not less than 100 percent,
``(D) any entity--
``(i)(I) which is incorporated as a nonprofit corporation
under a State law, or
``(II) which is described in section 501(c)(4) of the
Internal Revenue Code of 1986 and the activities of which
consist of providing commercial-type insurance (within the
meaning of section 501(m) of such Code), and
``(ii) for which the medical loss ratio (as so
determined)--
``(I) with respect to each of the individual, small group,
and large group insurance markets for such entity for the
calendar year is not less than 90 percent, and
``(II) with respect to all such markets for such entity for
the calendar year is not less than 92 percent, or
``(E) any entity--
``(i) which is a mutual insurance company,
``(ii) which for the period reported on the 2008 Accident
and Health Policy Experience Exhibit of the National
Association of Insurance Commissioners had--
``(I) a market share of the insured population of a State
of at least 40 but not more than 60 percent, and
``(II) with respect to all markets described in
subparagraph (D)(ii)(I), a medical loss ratio of not less
than 90 percent, and
``(iii) with respect to annual payment dates in calendar
years after 2011, for which the medical loss ratio
(determined in a manner consistent with the determination of
such ratio under section 2718(b)(1)(A) of the Public Health
Service Act) with respect to all such markets for such entity
for the preceding calendar year is not less than 89 percent
(except that with respect to such annual payment date for
2012, the calculation under 2718(b)(1)(B)(ii) of such Act is
determined by reference to the previous year, and with
respect to such annual payment date for 2013, such
calculation is determined by reference to the average for the
previous 2 years).''.
(d) Certain Insurance Exempted From Fee.--Paragraph (3) of
section 9010(h) of this Act is amended to read as follows:
``(3) Health insurance.--The term `health insurance' shall
not include--
``(A) any insurance coverage described in paragraph (1)(A)
or (3) of section 9832(c) of the Internal Revenue Code of
1986,
``(B) any insurance for long-term care, or
``(C) any medicare supplemental health insurance (as
defined in section 1882(g)(1) of the Social Security Act).''.
(e) Anti-avoidance Guidance.--Subsection (i) of section
9010 of this Act is amended by inserting ``and shall
prescribe such regulations as are necessary or appropriate to
prevent avoidance of the purposes of this section, including
inappropriate actions taken to qualify as an exempt entity
under subsection (c)(2)'' after ``section''.
(f) Conforming Amendments.--
(1) Section 9010(a)(1) of this Act is amended by striking
``2009'' and inserting ``2010''.
(2) Section 9010(c)(2)(B) of this Act is amended by
striking ``(except'' and all that follows through ``1323)''.
(3) Section 9010(c)(3) of this Act is amended by adding at
the end the following new sentence: ``If any entity described
in subparagraph (C)(i)(I), (D)(i)(I), or (E)(i) of paragraph
(2) is treated as a covered entity by reason of the
application of the preceding sentence, the net premiums
written with respect to health insurance for any United
States health risk of such entity shall not be taken into
account for purposes of this section.''.
(4) Section 9010(g)(1) of this Act is amended by striking
``and third party administration agreement fees''.
(5) Section 9010(j) of this Act is amended--
(A) by striking ``2008'' and inserting ``2009'', and
(B) by striking ``, and any third party administration
agreement fees received after such date''.
(g) Effective Date.--The amendments made by this section
shall take effect as if included in the enactment of section
9010.
SEC. 10906. MODIFICATIONS TO ADDITIONAL HOSPITAL INSURANCE
TAX ON HIGH-INCOME TAXPAYERS.
(a) FICA.--Section 3101(b)(2) of the Internal Revenue Code
of 1986, as added by section 9015(a)(1) of this Act, is
amended by striking ``0.5 percent'' and inserting ``0.9
percent''.
(b) SECA.--Section 1401(b)(2)(A) of the Internal Revenue
Code of 1986, as added by section 9015(b)(1) of this Act, is
amended by striking ``0.5 percent'' and inserting ``0.9
percent''.
(c) Effective Date.--The amendments made by this section
shall apply with respect to remuneration received, and
taxable years beginning, after December 31, 2012.
[[Page H2152]]
SEC. 10907. EXCISE TAX ON INDOOR TANNING SERVICES IN LIEU OF
ELECTIVE COSMETIC MEDICAL PROCEDURES.
(a) In General.--The provisions of, and amendments made by,
section 9017 of this Act are hereby deemed null, void, and of
no effect.
(b) Excise Tax on Indoor Tanning Services.--Subtitle D of
the Internal Revenue Code of 1986, as amended by this Act, is
amended by adding at the end the following new chapter:
``CHAPTER 49--COSMETIC SERVICES
``Sec. 5000B. Imposition of tax on indoor tanning services.
``SEC. 5000B. IMPOSITION OF TAX ON INDOOR TANNING SERVICES.
``(a) In General.--There is hereby imposed on any indoor
tanning service a tax equal to 10 percent of the amount paid
for such service (determined without regard to this section),
whether paid by insurance or otherwise.
``(b) Indoor Tanning Service.--For purposes of this
section--
``(1) In general.--The term `indoor tanning service' means
a service employing any electronic product designed to
incorporate 1 or more ultraviolet lamps and intended for the
irradiation of an individual by ultraviolet radiation, with
wavelengths in air between 200 and 400 nanometers, to induce
skin tanning.
``(2) Exclusion of phototherapy services.--Such term does
not include any phototherapy service performed by a licensed
medical professional.
``(c) Payment of Tax.--
``(1) In general.--The tax imposed by this section shall be
paid by the individual on whom the service is performed.
``(2) Collection.--Every person receiving a payment for
services on which a tax is imposed under subsection (a) shall
collect the amount of the tax from the individual on whom the
service is performed and remit such tax quarterly to the
Secretary at such time and in such manner as provided by the
Secretary.
``(3) Secondary liability.--Where any tax imposed by
subsection (a) is not paid at the time payments for indoor
tanning services are made, then to the extent that such tax
is not collected, such tax shall be paid by the person who
performs the service.''.
(c) Clerical Amendment.--The table of chapter for subtitle
D of the Internal Revenue Code of 1986, as amended by this
Act, is amended by inserting after the item relating to
chapter 48 the following new item:
``Chapter 49--Cosmetic Services''.
(d) Effective Date.--The amendments made by this section
shall apply to services performed on or after July 1, 2010.
SEC. 10908. EXCLUSION FOR ASSISTANCE PROVIDED TO PARTICIPANTS
IN STATE STUDENT LOAN REPAYMENT PROGRAMS FOR
CERTAIN HEALTH PROFESSIONALS.
(a) In General.--Paragraph (4) of section 108(f) of the
Internal Revenue Code of 1986 is amended to read as follows:
``(4) Payments under national health service corps loan
repayment program and certain state loan repayment
programs.--In the case of an individual, gross income shall
not include any amount received under section 338B(g) of the
Public Health Service Act, under a State program described in
section 338I of such Act, or under any other State loan
repayment or loan forgiveness program that is intended to
provide for the increased availability of health care
services in underserved or health professional shortage areas
(as determined by such State).''.
(b) Effective Date.--The amendment made by this section
shall apply to amounts received by an individual in taxable
years beginning after December 31, 2008.
SEC. 10909. EXPANSION OF ADOPTION CREDIT AND ADOPTION
ASSISTANCE PROGRAMS.
(a) Increase in Dollar Limitation.--
(1) Adoption credit.--
(A) In general.--Paragraph (1) of section 23(b) of the
Internal Revenue Code of 1986 (relating to dollar limitation)
is amended by striking ``$10,000'' and inserting ``$13,170''.
(B) Child with special needs.--Paragraph (3) of section
23(a) of such Code (relating to $10,000 credit for adoption
of child with special needs regardless of expenses) is
amended--
(i) in the text by striking ``$10,000'' and inserting
``$13,170'', and
(ii) in the heading by striking ``$10,000'' and inserting
``$13,170''.
(C) Conforming amendment to inflation adjustment.--
Subsection (h) of section 23 of such Code (relating to
adjustments for inflation) is amended to read as follows:
``(h) Adjustments for Inflation.--
``(1) Dollar limitations.--In the case of a taxable year
beginning after December 31, 2010, each of the dollar amounts
in subsections (a)(3) and (b)(1) shall be increased by an
amount equal to--
``(A) such dollar amount, multiplied by
``(B) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year in which the taxable
year begins, determined by substituting `calendar year 2009'
for `calendar year 1992' in subparagraph (B) thereof.
If any amount as increased under the preceding sentence is
not a multiple of $10, such amount shall be rounded to the
nearest multiple of $10.
``(2) Income limitation.--In the case of a taxable year
beginning after December 31, 2002, the dollar amount in
subsection (b)(2)(A)(i) shall be increased by an amount equal
to--
``(A) such dollar amount, multiplied by
``(B) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year in which the taxable
year begins, determined by substituting `calendar year 2001'
for `calendar year 1992' in subparagraph (B) thereof.
If any amount as increased under the preceding sentence is
not a multiple of $10, such amount shall be rounded to the
nearest multiple of $10.''.
(2) Adoption assistance programs.--
(A) In general.--Paragraph (1) of section 137(b) of the
Internal Revenue Code of 1986 (relating to dollar limitation)
is amended by striking ``$10,000'' and inserting ``$13,170''.
(B) Child with special needs.--Paragraph (2) of section
137(a) of such Code (relating to $10,000 exclusion for
adoption of child with special needs regardless of expenses)
is amended--
(i) in the text by striking ``$10,000'' and inserting
``$13,170'', and
(ii) in the heading by striking ``$10,000'' and inserting
``$13,170''.
(C) Conforming amendment to inflation adjustment.--
Subsection (f) of section 137 of such Code (relating to
adjustments for inflation) is amended to read as follows:
``(f) Adjustments for Inflation.--
``(1) Dollar limitations.--In the case of a taxable year
beginning after December 31, 2010, each of the dollar amounts
in subsections (a)(2) and (b)(1) shall be increased by an
amount equal to--
``(A) such dollar amount, multiplied by
``(B) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year in which the taxable
year begins, determined by substituting `calendar year 2009'
for `calendar year 1992' in subparagraph (B) thereof.
If any amount as increased under the preceding sentence is
not a multiple of $10, such amount shall be rounded to the
nearest multiple of $10.
``(2) Income limitation.--In the case of a taxable year
beginning after December 31, 2002, the dollar amount in
subsection (b)(2)(A) shall be increased by an amount equal
to--
``(A) such dollar amount, multiplied by
``(B) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year in which the taxable
year begins, determined by substituting `calendar year 2001'
for `calendar year 1992' in subparagraph thereof.
If any amount as increased under the preceding sentence is
not a multiple of $10, such amount shall be rounded to the
nearest multiple of $10.''.
(b) Credit Made Refundable.--
(1) Credit moved to subpart relating to refundable
credits.--The Internal Revenue Code of 1986 is amended--
(A) by redesignating section 23, as amended by subsection
(a), as section 36C, and
(B) by moving section 36C (as so redesignated) from subpart
A of part IV of subchapter A of chapter 1 to the location
immediately before section 37 in subpart C of part IV of
subchapter A of chapter 1.
(2) Conforming amendments.--
(A) Section 24(b)(3)(B) of such Code is amended by striking
``23,''.
(B) Section 25(e)(1)(C) of such Code is amended by striking
``23,'' both places it appears.
(C) Section 25A(i)(5)(B) of such Code is amended by
striking ``23, 25D,'' and inserting ``25D''.
(D) Section 25B(g)(2) of such Code is amended by striking
``23,''.
(E) Section 26(a)(1) of such Code is amended by striking
``23,''.
(F) Section 30(c)(2)(B)(ii) of such Code is amended by
striking ``23, 25D,'' and inserting ``25D''.
(G) Section 30B(g)(2)(B)(ii) of such Code is amended by
striking ``23,''.
(H) Section 30D(c)(2)(B)(ii) of such Code is amended by
striking ``sections 23 and'' and inserting ``section''.
(I) Section 36C of such Code, as so redesignated, is
amended--
(i) by striking paragraph (4) of subsection (b), and
(ii) by striking subsection (c).
(J) Section 137 of such Code is amended--
(i) by striking ``section 23(d)'' in subsection (d) and
inserting ``section 36C(d)'', and
(ii) by striking ``section 23'' in subsection (e) and
inserting ``section 36C''.
(K) Section 904(i) of such Code is amended by striking
``23,''.
(L) Section 1016(a)(26) is amended by striking ``23(g)''
and inserting ``36C(g)''.
(M) Section 1400C(d) of such Code is amended by striking
``23,''.
(N) Section 6211(b)(4)(A) of such Code is amended by
inserting ``36C,'' before ``53(e)''.
(O) The table of sections for subpart A of part IV of
subchapter A of chapter 1 of such Code of 1986 is amended by
striking the item relating to section 23.
(P) Paragraph (2) of section 1324(b) of title 31, United
States Code, as amended by this Act, is amended by inserting
``36C,'' after ``36B,''.
(Q) The table of sections for subpart C of part IV of
subchapter A of chapter 1 of the Internal Revenue Code of
1986, as amended by this Act, is amended by inserting after
the item relating to section 36B the following new item:
``Sec. 36C. Adoption expenses.''.
(c) Application and Extension of EGTRRA Sunset.--
Notwithstanding section 901 of the Economic Growth and Tax
Relief Reconciliation Act of 2001, such section shall apply
to the amendments made by this section and the amendments
made by section 202 of such Act by substituting ``December
31, 2011'' for ``December 31, 2010'' in subsection (a)(1)
thereof.
(d) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2009.
Amend the title so as to read: ``An Act entitled The
Patient Protection and Affordable Care Act.''.
Motion to Concur
The SPEAKER pro tempore. The Clerk will designate the motion.
The text of the motion is as follows:
Mr. Spratt moves that the House concur in the Senate
amendments to H.R. 3590.
[[Page H2153]]
The SPEAKER pro tempore. Pursuant to section 2 of House Resolution
1203, the previous question is ordered on the motion.
The question is on the motion.
The question was taken; and the Speaker pro tempore announced that
the ayes appeared to have it.
Recorded Vote
Mr. BOEHNER. Mr. Speaker, on that I request a recorded vote and
request that the Speaker exercise your discretion to conduct this vote
by a rollcall under clause 2 of House rule XX.
The SPEAKER pro tempore. A recorded vote is requested. Those favoring
a recorded vote will rise. A sufficient number having risen, a recorded
vote is ordered. Members will record their vote by electronic device.
=========================== NOTE ===========================
March 21, 2010 on page H2153 the following appeared: The Speaker
pro tempore. A recorded vote is requested. Those favoring a
recorded vote will rise. A sufficient number having risen, a
recorded vote is ordered.
The online version should be corrected to read: The Speaker pro
tempore. A recorded vote is requested. Those favoring a recorded
vote will rise. A sufficient number having risen, a recorded vote
is ordered. Members will record their vote by electronic device.
========================= END NOTE =========================
The vote was taken by electronic device, and there were--ayes 219,
noes 212, not voting 0, as follows:
[Roll No. 165]
AYES--219
Ackerman
Andrews
Baca
Baird
Baldwin
Bean
Becerra
Berkley
Berman
Bishop (GA)
Bishop (NY)
Blumenauer
Boccieri
Boswell
Boyd
Brady (PA)
Braley (IA)
Brown, Corrine
Butterfield
Capps
Capuano
Cardoza
Carnahan
Carney
Carson (IN)
Castor (FL)
Chu
Clarke
Clay
Cleaver
Clyburn
Cohen
Connolly (VA)
Conyers
Cooper
Costa
Costello
Courtney
Crowley
Cuellar
Cummings
Dahlkemper
Davis (CA)
Davis (IL)
DeFazio
DeGette
Delahunt
DeLauro
Dicks
Dingell
Doggett
Donnelly (IN)
Doyle
Driehaus
Edwards (MD)
Ellison
Ellsworth
Engel
Eshoo
Etheridge
Farr
Fattah
Filner
Foster
Frank (MA)
Fudge
Garamendi
Giffords
Gonzalez
Gordon (TN)
Grayson
Green, Al
Green, Gene
Grijalva
Gutierrez
Hall (NY)
Halvorson
Hare
Harman
Hastings (FL)
Heinrich
Higgins
Hill
Himes
Hinchey
Hinojosa
Hirono
Hodes
Holt
Honda
Hoyer
Inslee
Israel
Jackson (IL)
Jackson Lee (TX)
Johnson (GA)
Johnson, E. B.
Kagen
Kanjorski
Kaptur
Kennedy
Kildee
Kilpatrick (MI)
Kilroy
Kind
Kirkpatrick (AZ)
Klein (FL)
Kosmas
Kucinich
Langevin
Larsen (WA)
Larson (CT)
Lee (CA)
Levin
Lewis (GA)
Loebsack
Lofgren, Zoe
Lowey
Lujan
Maffei
Maloney
Markey (CO)
Markey (MA)
Matsui
McCarthy (NY)
McCollum
McDermott
McGovern
McNerney
Meek (FL)
Meeks (NY)
Michaud
Miller (NC)
Miller, George
Mitchell
Mollohan
Moore (KS)
Moore (WI)
Moran (VA)
Murphy (CT)
Murphy (NY)
Murphy, Patrick
Nadler (NY)
Napolitano
Neal (MA)
Oberstar
Obey
Olver
Ortiz
Owens
Pallone
Pascrell
Pastor (AZ)
Payne
Pelosi
Perlmutter
Perriello
Peters
Pingree (ME)
Polis (CO)
Pomeroy
Price (NC)
Quigley
Rahall
Rangel
Reyes
Richardson
Rodriguez
Rothman (NJ)
Roybal-Allard
Ruppersberger
Rush
Ryan (OH)
Salazar
Sanchez, Linda T.
Sanchez, Loretta
Sarbanes
Schakowsky
Schauer
Schiff
Schrader
Schwartz
Scott (GA)
Scott (VA)
Serrano
Sestak
Shea-Porter
Sherman
Sires
Slaughter
Smith (WA)
Snyder
Speier
Spratt
Stark
Stupak
Sutton
Thompson (CA)
Thompson (MS)
Tierney
Titus
Tonko
Towns
Tsongas
Van Hollen
Velazquez
Visclosky
Walz
Wasserman Schultz
Waters
Watson
Watt
Waxman
Weiner
Welch
Wilson (OH)
Woolsey
Wu
Yarmuth
NOES--212
Aderholt
Adler (NJ)
Akin
Alexander
Altmire
Arcuri
Austria
Bachmann
Bachus
Barrett (SC)
Barrow
Bartlett
Barton (TX)
Berry
Biggert
Bilbray
Bilirakis
Bishop (UT)
Blackburn
Blunt
Boehner
Bonner
Bono Mack
Boozman
Boren
Boucher
Boustany
Brady (TX)
Bright
Broun (GA)
Brown (SC)
Brown-Waite, Ginny
Buchanan
Burgess
Burton (IN)
Buyer
Calvert
Camp
Campbell
Cantor
Cao
Capito
Carter
Cassidy
Castle
Chaffetz
Chandler
Childers
Coble
Coffman (CO)
Cole
Conaway
Crenshaw
Culberson
Davis (AL)
Davis (KY)
Davis (TN)
Deal (GA)
Dent
Diaz-Balart, L.
Diaz-Balart, M.
Dreier
Duncan
Edwards (TX)
Ehlers
Emerson
Fallin
Flake
Fleming
Forbes
Fortenberry
Foxx
Franks (AZ)
Frelinghuysen
Gallegly
Garrett (NJ)
Gerlach
Gingrey (GA)
Gohmert
Goodlatte
Granger
Graves
Griffith
Guthrie
Hall (TX)
Harper
Hastings (WA)
Heller
Hensarling
Herger
Herseth Sandlin
Hoekstra
Holden
Hunter
Inglis
Issa
Jenkins
Johnson (IL)
Johnson, Sam
Jones
Jordan (OH)
King (IA)
King (NY)
Kingston
Kirk
Kissell
Kline (MN)
Kratovil
Lamborn
Lance
Latham
LaTourette
Latta
Lee (NY)
Lewis (CA)
Linder
Lipinski
LoBiondo
Lucas
Luetkemeyer
Lummis
Lungren, Daniel E.
Lynch
Mack
Manzullo
Marchant
Marshall
Matheson
McCarthy (CA)
McCaul
McClintock
McCotter
McHenry
McIntyre
McKeon
McMahon
McMorris Rodgers
Melancon
Mica
Miller (FL)
Miller (MI)
Miller, Gary
Minnick
Moran (KS)
Murphy, Tim
Myrick
Neugebauer
Nunes
Nye
Olson
Paul
Paulsen
Pence
Peterson
Petri
Pitts
Platts
Poe (TX)
Posey
Price (GA)
Putnam
Radanovich
Rehberg
Reichert
Roe (TN)
Rogers (AL)
Rogers (KY)
Rogers (MI)
Rohrabacher
Rooney
Ros-Lehtinen
Roskam
Ross
Royce
Ryan (WI)
Scalise
Schmidt
Schock
Sensenbrenner
Sessions
Shadegg
Shimkus
Shuler
Shuster
Simpson
Skelton
Smith (NE)
Smith (NJ)
Smith (TX)
Souder
Space
Stearns
Sullivan
Tanner
Taylor
Teague
Terry
Thompson (PA)
Thornberry
Tiahrt
Tiberi
Turner
Upton
Walden
Wamp
Westmoreland
Whitfield
Wilson (SC)
Wittman
Wolf
Young (AK)
Young (FL)
{time} 2249
So the motion to concur was agreed to.
The result of the vote was announced as above recorded.
A motion to reconsider was laid on the table.
Mr. HOYER. Mr. Speaker, pursuant to House Resolution 1203, I call up
the bill (H.R. 4872) to provide for reconciliation pursuant to section
202 of the concurrent resolution on the budget for fiscal year 2010,
and ask for its immediate consideration.
The Clerk read the title of the bill.
The SPEAKER pro tempore. Pursuant to section 3 of House Resolution
1203, the amendment in the nature of a substitute printed in part A of
House Report 111-448, modified by the amendment printed in part B of
the report is adopted and the bill, as amended, is considered read.
The text of the bill, as amended, is as follows:
H.R. 4872
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Health
Care and Education Reconciliation Act of 2010''.
(b) Table of Contents.--The table of contents of this Act
is as follows:
Sec. 1. Short title; table of contents.
TITLE I--COVERAGE, MEDICARE, MEDICAID, AND REVENUES
Subtitle A--Coverage
Sec. 1001. Affordability.
Sec. 1002. Individual responsibility.
Sec. 1003. Employer responsibility.
Sec. 1004. Income definitions.
Sec. 1005. Implementation funding.
Subtitle B--Medicare
Sec. 1101. Closing the medicare prescription drug ``donut hole''.
Sec. 1102. Medicare Advantage payments.
Sec. 1103. Savings from limits on MA plan administrative costs.
Sec. 1104. Disproportionate share hospital (DSH) payments.
Sec. 1105. Market basket updates.
Sec. 1106. Physician ownership-referral.
Sec. 1107. Payment for imaging services.
Subtitle C--Medicaid
Sec. 1201. Federal funding for States.
Sec. 1202. Payments to primary care physicians.
Sec. 1203. Disproportionate share hospital payments.
Sec. 1204. Funding for the territories.
Sec. 1205. Delay in Community First Choice option.
Sec. 1206. Drug rebates for new formulations of existing drugs.
Subtitle D--Reducing Fraud, Waste, and Abuse
Sec. 1301. Community mental health centers.
Sec. 1302. Medicare prepayment medical review limitations.
Sec. 1303. CMS-IRS data match to identify fraudulent providers.
Sec. 1304. Funding to fight fraud, waste, and abuse.
Sec. 1305. 90-day period of enhanced oversight for initial claims of
DME suppliers.
Subtitle E--Provisions Relating to Revenue
Sec. 1401. High-cost plan excise tax.
Sec. 1402. Medicare tax.
Sec. 1403. Delay of limitation on health flexible spending arrangements
under cafeteria plans.
Sec. 1404. Brand name pharmaceuticals.
Sec. 1405. Excise tax on medical device manufacturers.
Sec. 1406. Health insurance providers.
Sec. 1407. Delay of elimination of deduction for expenses allocable to
medicare part D subsidy.
Sec. 1408. Elimination of unintended application of cellulosic biofuel
producer credit.
Sec. 1409. Codification of economic substance doctrine and penalties.
Sec. 1410. Time for payment of corporate estimated taxes.
Sec. 1411. No impact on Social Security trust funds.
[[Page H2154]]
Subtitle F--Other Provisions
Sec. 1501. Community college and career training grant program.
TITLE II--EDUCATION AND HEALTH
Subtitle A--Education
Sec. 2001. Short title; references.
Part I--Investing in Students and Families
Sec. 2101. Federal Pell Grants.
Sec. 2102. Student financial assistance.
Sec. 2103. College access challenge grant program.
Sec. 2104. Investment in historically black colleges and universities
and minority-serving institutions.
Part II--Student Loan Reform
Sec. 2201. Termination of Federal Family Education Loan appropriations.
Sec. 2202. Termination of Federal loan insurance program.
Sec. 2203. Termination of applicable interest rates.
Sec. 2204. Termination of Federal payments to reduce student interest
costs.
Sec. 2205. Termination of FFEL PLUS Loans.
Sec. 2206. Federal Consolidation Loans.
Sec. 2207. Termination of Unsubsidized Stafford Loans for middle-income
borrowers.
Sec. 2208. Termination of special allowances.
Sec. 2209. Origination of Direct Loans at institutions outside the
United States.
Sec. 2210. Conforming amendments.
Sec. 2211. Terms and conditions of loans.
Sec. 2212. Contracts; mandatory funds.
Sec. 2213. Agreements with State-owned banks.
Sec. 2214. Income-based repayment.
Subtitle B--Health
Sec. 2301. Insurance reforms.
Sec. 2302. Drugs purchased by covered entities.
Sec. 2303. Community health centers.
TITLE I--COVERAGE, MEDICARE, MEDICAID, AND REVENUES
Subtitle A--Coverage
SEC. 1001. TAX CREDITS.
(a) Premium Tax Credits.--Section 36B of the Internal
Revenue Code of 1986, as added by section 1401 of the Patient
Protection and Affordable Care Act and amended by section
10105 of such Act, is amended--
(1) in subsection (b)(3)(A)--
(A) in clause (i), by striking ``with respect to any
taxpayer'' and all that follows up to the end period and
inserting ``for any taxable year shall be the percentage such
that the applicable percentage for any taxpayer whose
household income is within an income tier specified in the
following table 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:
``In the case of household
income (expressed as a
percent of poverty line) The initial premium The final premium
within the following income percentage is-- percentage is--
tier:
Up to 133% 2.0% 2.0%
133% up to 150% 3.0% 4.0%
150% up to 200% 4.0% 6.3%
200% up to 250% 6.3% 8.05%
250% up to 300% 8.05% 9.5%
300% up to 400% 9.5% 9.5%''; and
(B) by striking clauses (ii) and (iii), and inserting the
following:
``(ii) Indexing.--
``(I) In general.--Subject to subclause (II), in the case
of taxable years beginning in any calendar year after 2014,
the initial and final applicable percentages under clause (i)
(as in effect for the preceding calendar year after
application of this clause) shall be adjusted to reflect the
excess of the rate of premium growth for the preceding
calendar year over the rate of income growth for the
preceding calendar year.
``(II) Additional adjustment.--Except as provided in
subclause (III), in the case of any calendar year after 2018,
the percentages described in subclause (I) shall, in addition
to the adjustment under subclause (I), be adjusted to reflect
the excess (if any) of the rate of premium growth estimated
under subclause (I) for the preceding calendar year over the
rate of growth in the consumer price index for the preceding
calendar year.
``(III) Failsafe.--Subclause (II) shall apply for any
calendar year only if the aggregate amount of premium tax
credits under this section and cost-sharing reductions under
section 1402 of the Patient Protection and Affordable Care
Act for the preceding calendar year exceeds an amount equal
to 0.504 percent of the gross domestic product for the
preceding calendar year.''; and
(2) in subsection (c)(2)(C)--
(A) by striking ``9.8 percent'' in clauses (i)(II) and (iv)
and inserting ``9.5 percent'', and
(B) by striking ``(b)(3)(A)(iii)'' in clause (iv) and
inserting ``(b)(3)(A)(ii)''.
(b) Cost Sharing.--Section 1402(c) of the Patient
Protection and Affordable Care Act is amended--
(1) in paragraph (1)(B)(i)--
(A) in subclause (I), by striking ``90'' and inserting
``94'';
(B) in subclause (II)--
(i) by striking ``80'' and inserting ``87''; and
(ii) by striking ``and''; and
(C) by striking subclause (III) and inserting the
following:
``(III) 73 percent in the case of an eligible insured whose
household income is more than 200 percent but not more than
250 percent of the poverty line for a family of the size
involved; and
``(IV) 70 percent in the case of an eligible insured whose
household income is more than 250 percent but not more than
400 percent of the poverty line for a family of the size
involved.''; and
(2) in paragraph (2)--
(A) in subparagraph (A)--
(i) by striking ``90'' and inserting ``94''; and
(ii) by striking ``and'';
(B) in subparagraph (B)--
(i) by striking ``80'' and inserting ``87''; and
(ii) by striking the period and inserting ``; and''; and
(C) by inserting after subparagraph (B) the following new
subparagraph:
``(C) in the case of an eligible insured whose household
income is more than 200 percent but not more than 250 percent
of the poverty line for a family of the size involved,
increase the plan's share of the total allowed costs of
benefits provided under the plan to 73 percent of such
costs.''.
SEC. 1002. INDIVIDUAL RESPONSIBILITY.
(a) Amounts.--Section 5000A(c) of the Internal Revenue Code
of 1986, as added by section 1501(b) of the Patient
Protection and Affordable Care Act and amended by section
10106 of such Act, is amended--
(1) in paragraph (2)(B)--
(A) in the matter preceding clause (i), by--
(i) inserting ``the excess of'' before ``the taxpayer's
household income''; and
(ii) inserting ``for the taxable year over the amount of
gross income specified in section 6012(a)(1) with respect to
the taxpayer'' before ``for the taxable year'';
(B) in clause (i), by striking ``0.5'' and inserting
``1.0'';
(C) in clause (ii), by striking ``1.0'' and inserting
``2.0''; and
(D) in clause (iii), by striking ``2.0'' and inserting
``2.5''; and
(2) in paragraph (3)--
(A) in subparagraph (A), by striking ``$750'' and inserting
``$695'';
(B) in subparagraph (B), by striking ``$495'' and inserting
``$325''; and
(C) in subparagraph (D)--
(i) in the matter preceding clause (i), by striking
``$750'' and inserting ``$695''; and
(ii) in clause (i), by striking ``$750'' and inserting
``$695''.
(b) Threshold.--Section 5000A of such Code, as so added and
amended, is amended--
(1) by striking subsection (c)(4)(D); and
(2) in subsection (e)(2)--
(A) by striking ``under 100 percent of poverty line'' and
inserting ``below filing threshold''; and
(B) by striking all that follows ``less than'' and
inserting ``the amount of gross income specified in section
6012(a)(1) with respect to the taxpayer.''.
SEC. 1003. EMPLOYER RESPONSIBILITY.
(a) Payment Calculation.--Subparagraph (D) of subsection
(d)(2) of section 4980H of the Internal Revenue Code of 1986,
as added by section 1513 of the Patient Protection and
Affordable Care Act and amended by section 10106 of such Act,
is amended to read as follows:
``(D) Application of employer size to assessable
penalties.--
``(i) In general.--The number of individuals employed by an
applicable large employer as full-time employees during any
month shall be reduced by 30 solely for purposes of
calculating--
``(I) the assessable payment under subsection (a), or
``(II) the overall limitation under subsection (b)(2).
``(ii) Aggregation.--In the case of persons treated as 1
employer under subparagraph (C)(i), only 1 reduction under
subclause (I) or (II) shall be allowed with respect to such
persons and such reduction shall be allocated among such
persons ratably on the basis of the number of full-time
employees employed by each such person.''.
(b) Applicable Payment Amount.--Section 4980H of such Code,
as so added and amended, is amended--
(1) in the flush text following subsection (c)(1)(B), by
striking ``400 percent of the applicable payment amount'' and
inserting ``an amount equal to \1/12\ of $3,000'';
(2) in subsection (d)(1), by striking ``$750'' and
inserting ``$2,000''; and
(3) in subsection (d)(5)(A), in the matter preceding clause
(i), by striking ``subsection (b)(2) and (d)(1)'' and
inserting ``subsection (b) and paragraph (1)''.
(c) Counting Part-Time Workers in Setting the Threshold for
Employer Responsibility.--Section 4980H(d)(2) of such Code,
as so added and amended and as amended by subsection (a), is
amended by adding at the end the following new subparagraph:
``(E) Full-time equivalents treated as full-time
employees.--Solely for purposes of determining whether an
employer is an applicable large employer under this
paragraph, an employer shall, in addition to the number of
full-time employees for any month otherwise determined,
include for such month a number of full-time employees
determined by dividing the aggregate number of hours of
service of employees who are not full-time employees for the
month by 120.''.
(d) Eliminating Waiting Period Assessment.--Section 4980H
of such Code, as so added
[[Page H2155]]
and amended and as amended by the preceding subsections, is
amended by striking subsection (b) and redesignating
subsections (c), (d), and (e) as subsections (b), (c), and
(d), respectively.
SEC. 1004. INCOME DEFINITIONS.
(a) Modified Adjusted Gross Income.--
(1) In general.--The following provisions of the Internal
Revenue Code of 1986 are each amended by striking ``modified
gross'' each place it appears and inserting ``modified
adjusted gross'':
(A) Clauses (i) and (ii) of section 36B(d)(2)(A), as added
by section 1401 of the Patient Protection and Affordable Care
Act.
(B) Section 6103(l)(21)(A)(iv), as added by section 1414 of
such Act.
(C) Clauses (i) and (ii) of section 5000A(c)(4), as added
by section 1501(b) of such Act.
(2) Definition.--
(A) Section 36B(d)(2)(B) of such Code, as so added, is
amended to read as follows:
``(B) Modified adjusted gross income.--The term `modified
adjusted gross income' means adjusted gross income increased
by--
``(i) any amount excluded from gross income under section
911, and
``(ii) any amount of interest received or accrued by the
taxpayer during the taxable year which is exempt from tax.''.
(B) Section 5000A(c)(4)(C) of such Code, as so added, is
amended to read as follows:
``(C) Modified adjusted gross income.--The term `modified
adjusted gross income' means adjusted gross income increased
by--
``(i) any amount excluded from gross income under section
911, and
``(ii) any amount of interest received or accrued by the
taxpayer during the taxable year which is exempt from tax.''.
(b) Modified Adjusted Gross Income Definition.--
(1) Medicaid.--Section 1902 of the Social Security Act (42
U.S.C. 1396a) is amended by striking ``modified gross
income'' each place it appears in the text and headings of
the following provisions and inserting ``modified adjusted
gross income'':
(A) Paragraph (14) of subsection (e), as added by section
2002(a) of the Patient Protection and Affordable Care Act.
(B) Subsection (gg)(4)(A), as added by section 2001(b) of
such Act.
(2) Chip.--
(A) State plan requirements.--Section 2102(b)(1)(B)(v) of
the Social Security Act (42 U.S.C. 1397bb(b)(1)(B)(v)), as
added by section 2101(d)(1) of the Patient Protection and
Affordable Care Act, is amended by striking ``modified gross
income'' and inserting ``modified adjusted gross income''.
(B) Plan administration.--Section 2107(e)(1)(E) of the
Social Security Act (42 U.S.C. 1397gg(e)(1)(E)), as added by
section 2101(d)(2) of the Patient Protection and Affordable
Care Act, is amended by striking ``modified gross income''
and inserting ``modified adjusted gross income''.
(c) No Excess Payments.--Section 36B(f) of the Internal
Revenue Code of 1986, as added by section 1401(a) of the
Patient Protection and Affordable Care Act, is amended by
adding at the end the following new paragraph:
``(3) Information requirement.--Each Exchange (or any
person carrying out 1 or more responsibilities of an Exchange
under section 1311(f)(3) or 1321(c) of the Patient Protection
and Affordable Care Act) shall provide the following
information to the Secretary and to the taxpayer with respect
to any health plan provided through the Exchange:
``(A) The level of coverage described in section 1302(d) of
the Patient Protection and Affordable Care Act and the period
such coverage was in effect.
``(B) The total premium for the coverage without regard to
the credit under this section or cost-sharing reductions
under section 1402 of such Act.
``(C) The aggregate amount of any advance payment of such
credit or reductions under section 1412 of such Act.
``(D) The name, address, and TIN of the primary insured and
the name and TIN of each other individual obtaining coverage
under the policy.
``(E) Any information provided to the Exchange, including
any change of circumstances, necessary to determine
eligibility for, and the amount of, such credit.
``(F) Information necessary to determine whether a taxpayer
has received excess advance payments.''.
(d) Adult Dependents.--
(1) Exclusion of amounts expended for medical care.--The
first sentence of section 105(b) of the Internal Revenue Code
of 1986 (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 child (as defined in section 152(f)(1)) of the taxpayer
who as of the end of the taxable year has not attained age
27''.
(2) Self-employed health insurance deduction.--Section
162(l)(1) of such Code 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, and
``(D) any child (as defined in section 152(f)(1)) of the
taxpayer who as of the end of the taxable year has not
attained age 27.''.
(3) Coverage under self-employed deduction.--Section
162(l)(2)(B) of such Code is amended by inserting ``, or any
dependent, or individual described in subparagraph (D) of
paragraph (1) with respect to,'' after ``spouse of''.
(4) Sick and accident benefits provided to members of a
voluntary employees' beneficiary association and their
dependents.--Section 501(c)(9) of such Code 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
`dependent' shall include any individual who is a child (as
defined in section 152(f)(1)) of a member who as of the end
of the calendar year has not attained age 27.''.
(5) Medical and other benefits for retired employees.--
Section 401(h) of such Code is amended by adding at the end
the following: ``For purposes of this subsection, the term
`dependent' shall include any individual who is a child (as
defined in section 152(f)(1)) of a retired employee who as of
the end of the calendar year has not attained age 27.''.
(e) Five Percent Income Disregard for Certain
Individuals.--Section 1902(e)(14) of the Social Security Act
(42 U.S.C. 1396a(e)(14)), as amended by subsection (b)(1), is
further amended--
(1) in subparagraph (B), by striking ``No type'' and
inserting ``Subject to subparagraph (I), no type''; and
(2) by adding at the end the following new subparagraph:
``(I) Treatment of portion of modified adjusted gross
income.--For purposes of determining the income eligibility
of an individual for medical assistance whose eligibility is
determined based on the application of modified adjusted
gross income under subparagraph (A), the State shall--
``(i) determine the dollar equivalent of the difference
between the upper income limit on eligibility for such an
individual (expressed as a percentage of the poverty line)
and such upper income limit increased by 5 percentage points;
and
``(ii) notwithstanding the requirement in subparagraph (A)
with respect to use of modified adjusted gross income,
utilize as the applicable income of such individual, in
determining such income eligibility, an amount equal to the
modified adjusted gross income applicable to such individual
reduced by such dollar equivalent amount.''.
SEC. 1005. IMPLEMENTATION FUNDING.
(a) In General.--There is hereby established a Health
Insurance Reform Implementation Fund (referred to in this
section as the ``Fund'') within the Department of Health and
Human Services to carry out the Patient Protection and
Affordable Care Act and this Act (and the amendments made by
such Acts).
(b) Funding.--There is appropriated to the Fund, out of any
funds in the Treasury not otherwise appropriated,
$1,000,000,000 for Federal administrative expenses to carry
out such Act (and the amendments made by such Acts).
Subtitle B--Medicare
SEC. 1101. CLOSING THE MEDICARE PRESCRIPTION DRUG ``DONUT
HOLE''.
(a) Coverage Gap Rebate for 2010.--
(1) In general.--Section 1860D-42 of the Social Security
Act (42 U.S.C. 1395w-152) is amended by adding at the end the
following new subsection:
``(c) Coverage Gap Rebate for 2010.--
``(1) In general.--In the case of an individual described
in subparagraphs (A) through (D) of section 1860D-14A(g)(1)
who as of the last day of a calendar quarter in 2010 has
incurred costs for covered part D drugs so that the
individual has exceeded the initial coverage limit under
section 1860D-2(b)(3) for 2010, the Secretary shall provide
for payment from the Medicare Prescription Drug Account of
$250 to the individual by not later than the 15th day of the
third month following the end of such quarter.
``(2) Limitation.--The Secretary shall provide only 1
payment under this subsection with respect to any
individual.''.
(2) Repeal of provision.--Section 3315 of the Patient
Protection and Affordable Care Act (including the amendments
made by such section) is repealed, and any provision of law
amended or repealed by such sections is hereby restored or
revived as if such section had not been enacted into law.
(b) Closing the Donut Hole.--Part D of title XVIII of the
Social Security Act (42 U.S.C. 1395w-101 et seq.), as amended
by section 3301 of the Patient Protection and Affordable Care
Act, is further amended--
(1) in section 1860D-43--
(A) in subsection (b), by striking ``July 1, 2010'' and
inserting ``January 1, 2011''; and
(B) in subsection (c)(2), by striking ``July 1, 2010, and
ending on December 31, 2010,'' and inserting ``January 1,
2011, and December 31, 2011,'';
(2) in section 1860D-14A--
(A) in subsection (a)--
(i) by striking ``July 1, 2010'' and inserting ``January 1,
2011''; and
(ii) by striking ``April 1, 2010'' and inserting ``180 days
after the date of the enactment of this section'';
(B) in subsection (b)(1)(C)--
(i) in the heading, by striking ``2010 and'';
(ii) by striking ``July 1, 2010'' and inserting ``January
1, 2011''; and
(iii) by striking ``May 1, 2010'' and inserting ``not later
than 30 days after the date of the establishment of a model
agreement under subsection (a)'';
(C) in subsection (c)--
(i) in paragraph (1)(A)(iii), by striking ``July 1, 2010,
and ending on December 31, 2011'' and inserting ``January 1,
2011, and ending on December 31, 2011''; and
(ii) in paragraph (2), by striking ``2010'' and inserting
``2011'';
[[Page H2156]]
(D) in subsection (d)(2)(B), by striking ``July 1, 2010,
and ending on December 31, 2010'' and inserting ``January 1,
2011, and ending on December 31, 2011''; and
(E) in subsection (g)(1)--
(i) in the matter before subparagraph (A), by striking ``an
applicable drug'' and inserting ``a covered part D drug'';
(ii) by adding ``and'' at the end of subparagraph (C);
(iii) by striking subparagraph (D); and
(iv) by redesignating subparagraph (E) as subparagraph (D);
and
(3) in section 1860D-2(b)--
(A) in paragraph (2)(A), by striking ``The coverage'' and
inserting ``Subject to subparagraphs (C) and (D), the
coverage'';
(B) in paragraph (2)(B), by striking ``subparagraph
(A)(ii)'' and inserting ``subparagraphs (A)(ii), (C), and
(D)'';
(C) by adding at the end of paragraph (2) the following new
subparagraphs:
``(C) Coverage for generic drugs in coverage gap.--
``(i) In general.--Except as provided in paragraph (4), the
coverage for an applicable beneficiary (as defined in section
1860D-14A(g)(1)) has coinsurance (for costs above the initial
coverage limit under paragraph (3) and below the out-of-
pocket threshold) for covered part D drugs that are not
applicable drugs under section 1860D-14A(g)(2) that is--
``(I) equal to the generic-gap coinsurance percentage
(specified in clause (ii)) for the year, or
``(II) actuarially equivalent (using processes and methods
established under section 1860D-11(c)) to an average expected
payment of such percentage of such costs for covered part D
drugs that are not applicable drugs under section 1860D-
14A(g)(2).
``(ii) Generic-gap coinsurance percentage.--The generic-gap
coinsurance percentage specified in this clause for--
``(I) 2011 is 93 percent;
``(II) 2012 and each succeeding year before 2020 is the
generic-gap coinsurance percentage under this clause for the
previous year decreased by 7 percentage points; and
``(III) 2020 and each subsequent year is 25 percent.
``(D) Coverage for applicable drugs in coverage gap.--
``(i) In general.--Except as provided in paragraph (4), the
coverage for an applicable beneficiary (as defined in section
1860D-14A(g)(1)) has coinsurance (for costs above the initial
coverage limit under paragraph (3) and below the out-of-
pocket threshold) for the negotiated price (as defined in
section 1860D-14A(g)(6)) of covered part D drugs that are
applicable drugs under section 1860D-14A(g)(2) that is--
``(I) equal to the difference between the applicable gap
percentage (specified in clause (ii) for the year) and the
discount percentage specified in section 1860D-14A(g)(4)(A)
for such applicable drugs, or
``(II) actuarially equivalent (using processes and methods
established under section 1860D-11(c)) to an average expected
payment of such percentage of such costs, for covered part D
drugs that are applicable drugs under section 1860D-
14A(g)(2).
``(ii) Applicable gap percentage.--The applicable gap
percentage specified in this clause for--
``(I) 2013 and 2014 is 97.5 percent;
``(II) 2015 and 2016 is 95 percent;
``(III) 2017 is 90 percent;
``(IV) 2018 is 85 percent;
``(V) 2019 is 80 percent; and
``(VI) 2020 and each subsequent year is 75 percent.'';
(D) in paragraph (3)(A), as restored under subsection
(a)(2), by striking ``paragraph (4)'' and inserting
``paragraphs (2)(C), (2)(D), and (4)'';
(E) in paragraph (4)(E), by inserting before the period at
the end the following: ``, except that incurred costs shall
not include the portion of the negotiated price that
represents the reduction in coinsurance resulting from the
application of paragraph (2)(D)''; and
(4) in section 1860D-22(a)(2)(A), by inserting before the
period at the end the following: ``, not taking into account
the value of any discount or coverage provided during the gap
in prescription drug coverage that occurs between the initial
coverage limit under section 1860D-2(b)(3) during the year
and the out-of-pocket threshold specified in section 1860D-
2(b)(4)(B)''.
(c) Conforming Amendment to AMP Under Medicaid.--Section
1927(k)(1)(B)(i) of the Social Security Act (42 U.S.C. 1396r-
8(k)(1)(B)(i)), as amended by section 2503(a)(2)(B) of the
Patient Protection and Affordable Care Act, is amended--
(1) by striking ``and'' at the end of subclause (III);
(2) by striking the period at the end of subclause (IV);
and
(3) by adding at the end the following new subclause:
``(V) discounts provided by manufacturers under section
1860D-14A.''.
(d) Reducing Growth Rate of Out-of-pocket Cost Threshold.--
Section 1860D-2(b) of the Social Security Act (42 U.S.C.
1395w-102(b)) is amended--
(1) in paragraph (4)(B)(i)--
(A) in subclause (I), by striking ``or'' at the end;
(B) by redesignating subclause (II) as subclause (VI); and
(C) by inserting after subclause (I) the following new
subclauses:
``(II) for each of years 2007 through 2013, is equal to the
amount specified in this subparagraph for the previous year,
increased by the annual percentage increase described in
paragraph (6) for the year involved;
``(III) for 2014 and 2015, is equal to the amount specified
in this subparagraph for the previous year, increased by the
annual percentage increase described in paragraph (6) for the
year involved, minus 0.25 percentage point;
``(IV) for each of years 2016 through 2019, is equal to the
amount specified in this subparagraph for the previous year,
increased by the lesser of--
``(aa) the annual percentage increase described in
paragraph (7) for the year involved, plus 2 percentage
points; or
``(bb) the annual percentage increase described in
paragraph (6) for the year;
``(V) for 2020, is equal to the amount that would have been
applied under this subparagraph for 2020 if the amendments
made by section 1101(d)(1) of the Health Care and Education
Reconciliation Act of 2010 had not been enacted; or''; and
(2) by adding at the end the following new paragraph:
(7) Additional annual percentage increase.--The annual
percentage increase specified in this paragraph for a year is
equal to the annual percentage increase in the consumer price
index for all urban consumers (United States city average)
for the 12-month period ending in July of the previous
year.''.
SEC. 1102. MEDICARE ADVANTAGE PAYMENTS.
(a) Repeal.--Effective as if included in the enactment of
the Patient Protection and Affordable Care Act, sections 3201
and 3203 of such Act (and the amendments made by such
sections) are repealed.
(b) Phase-in of Modified Benchmarks.--Section 1853 of the
Social Security Act (42 U.S.C. 1395w-23) is amended--
(1) in subsection (j)(1)(A), by striking ``(or, beginning
with 2007, \1/12\ of the applicable amount determined under
subsection (k)(1)) for the area for the year'' and inserting
`` for the area for the year (or, for 2007, 2008, 2009, and
2010, \1/12\ of the applicable amount determined under
subsection (k)(1) for the area for the year; for 2011, \1/12\
of the applicable amount determined under subsection (k)(1)
for the area for 2010; and, beginning with 2012, \1/12\ of
the blended benchmark amount determined under subsection
(n)(1) for the area for the year)''; 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), (4), and (5), the term `blended benchmark
amount' means for an area--
``(A) for 2012 the sum of--
``(i) \1/2\ of the applicable amount for the area and year;
and
``(ii) \1/2\ of the amount specified in paragraph (2)(A)
for the area and year; and
``(B) for a subsequent year the amount specified in
paragraph (2)(A) for the area and year.
``(2) Specified amount.--
``(A) In general.--The amount specified in this
subparagraph for an area and year is the product of--
``(i) the base payment amount specified in subparagraph (E)
for the area and year adjusted to take into account the
phase-out in the indirect costs of medical education from
capitation rates described in subsection (k)(4); and
``(ii) the applicable percentage for the area for the year
specified under subparagraph (B).
``(B) Applicable percentage.--Subject to subparagraph (D),
the applicable percentage specified in this subparagraph for
an area for a year in the case of an area that is ranked--
``(i) in the highest quartile under subparagraph (C) for
the previous year is 95 percent;
``(ii) in the second highest quartile under such
subparagraph for the previous year is 100 percent;
``(iii) in the third highest quartile under such
subparagraph for the previous year is 107.5 percent; or
``(iv) in the lowest quartile under such subparagraph for
the previous year is 115 percent.
``(C) Periodic ranking.--For purposes of this paragraph in
the case of an area located--
``(i) in 1 of the 50 States or the District of Columbia,
the Secretary shall rank such area in each year specified
under subsection (c)(1)(D)(ii) based upon the level of the
amount specified in subparagraph (A)(i) for such areas; or
``(ii) in a territory, the Secretary shall rank such areas
in each such year based upon the level of the amount
specified in subparagraph (A)(i) for such area relative to
quartile rankings computed under clause (i).
``(D) 1-year transition for changes in applicable
percentage.--If, for a year after 2012, there is a change in
the quartile in which an area is ranked compared to the
previous year, the applicable percentage for the area in the
year shall be the average of--
``(i) the applicable percentage for the area for the
previous year; and
``(ii) the applicable percentage that would otherwise apply
for the area for the year.
``(E) Base payment amount.--Subject to subparagraph (F),
the base payment amount specified in this subparagraph--
``(i) for 2012 is the amount specified in subsection
(c)(1)(D) for the area for the year; or
``(ii) for a subsequent year that--
``(I) is not specified under subsection (c)(1)(D)(ii), is
the base amount specified in this subparagraph for the area
for the previous year, increased by the national per capita
MA growth percentage, described in subsection (c)(6) for that
succeeding year, but not taking into account any adjustment
under subparagraph (C) of such subsection for a year before
2004; and
``(II) is specified under subsection (c)(1)(D)(ii), is the
amount specified in subsection (c)(1)(D) for the area for the
year.
``(F) Application of indirect medical education phase-
out.--The base payment amount specified in subparagraph (E)
for a year shall be adjusted in the same manner under
paragraph
[[Page H2157]]
(4) of subsection (k) as the applicable amount is adjusted
under such subsection.
``(3) Alternative phase-ins.--
``(A) 4-year phase-in for certain areas.--If the difference
between the applicable amount (as defined in subsection (k))
for an area for 2010 and the projected 2010 benchmark amount
(as defined in subparagraph (C)) for the area is at least $30
but less than $50, the blended benchmark amount for the area
is--
``(i) for 2012 the sum of--
``(I) \3/4\ of the applicable amount for the area and year;
and
``(II) \1/4\ of the amount specified in paragraph (2)(A)
for the area and year;
``(ii) for 2013 the sum of--
``(I) \1/2\ of the applicable amount for the area and year;
and
``(II) \1/2\ of the amount specified in paragraph (2)(A)
for the area and year;
``(iii) for 2014 the sum of--
``(I) \1/4\ of the applicable amount for the area and year;
and
``(II) \3/4\ of the amount specified in paragraph (2)(A)
for the area and year; and
``(iv) for a subsequent year the amount specified in
paragraph (2)(A) for the area and year.
``(B) 6-year phase-in for certain areas.--If the difference
between the applicable amount (as defined in subsection (k))
for an area for 2010 and the projected 2010 benchmark amount
(as defined in subparagraph (C)) for the area is at least
$50, the blended benchmark amount for the area is--
``(i) for 2012 the sum of--
``(I) \5/6\ of the applicable amount for the area and year;
and
``(II) \1/6\ of the amount specified in paragraph (2)(A)
for the area and year;
``(ii) for 2013 the sum of--
``(I) \2/3\ of the applicable amount for the area and year;
and
``(II) \1/3\ of the amount specified in paragraph (2)(A)
for the area and year;
``(iii) for 2014 the sum of--
``(I) \1/2\ of the applicable amount for the area and year;
and
``(II) \1/2\ of the amount specified in paragraph (2)(A)
for the area and year;
``(iv) for 2015 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)(A)
for the area and year; and
``(v) for 2016 the sum of--
``(I) \1/6\ of the applicable amount for the area and year;
and
``(II) \5/6\ of the amount specified in paragraph (2)(A)
for the area and year; and
``(vi) for a subsequent year the amount specified in
paragraph (2)(A) for the area and year.
``(C) Projected 2010 benchmark amount.--The projected 2010
benchmark amount described in this subparagraph for an area
is equal to the sum of--
``(i) \1/2\ of the applicable amount (as defined in
subsection (k)) for the area for 2010; and
``(ii) \1/2\ of the amount specified in paragraph (2)(A)
for the area for 2010 but determined as if there were
substituted for the applicable percentage specified in clause
(ii) of such paragraph the sum of--
``(I) the applicable percent that would be specified under
subparagraph (B) of paragraph (2) (determined without regard
to subparagraph (D) of such paragraph) for the area for 2010
if any reference in such paragraph to `the previous year'
were deemed a reference to 2010; and
``(II) the applicable percentage increase that would apply
to a qualifying plan in the area under subsection (o) as if
any reference in such subsection to 2012 were deemed a
reference to 2010 and as if the determination of a qualifying
county under paragraph (3)(B) of such subsection were made
for 2010.
``(4) Cap on benchmark amount.--In no case shall the
blended benchmark amount for an area for a year (determined
taking into account subsection (o)) be greater than the
applicable amount that would (but for the application of this
subsection) be determined under subsection (k)(1) for the
area for the year.
``(5) Non-application to pace plans.--This subsection shall
not apply to payments to a PACE program under section
1894.''.
(c) Applicable Percentage Quality Increases.--Section 1853
of such Act (42 U.S.C. 1395w-23), as amended by subsection
(b), is amended--
(1) in subsection (j), by inserting ``subject to subsection
(o),'' after ``For purposes of this part,'';
(2) in subsection (n)(2)(B), as added by subsection (b), by
inserting ``, subject to subsection (o)'' after ``as
follows''; and
(3) by adding at the end the following new subsection:
``(o) Applicable Percentage Quality Increases.--
``(1) In general.--Subject to the succeeding paragraphs, in
the case of a qualifying plan with respect to a year
beginning with 2012, the applicable percentage under
subsection (n)(2)(B) shall be increased on a plan or contract
level, as determined by the Secretary--
``(A) for 2012, by 1.5 percentage points;
``(B) for 2013, by 3.0 percentage points; and
``(C) for 2014 or a subsequent year, by 5.0 percentage
points.
``(2) Increase for qualifying plans in qualifying
counties.--The increase applied under paragraph (1) for a
qualifying plan located in a qualifying county for a year
shall be doubled.
``(3) Qualifying plans and qualifying county defined;
application of increases to low enrollment and new plans.--
For purposes of this subsection:
``(A) Qualifying plan.--
``(i) In general.--The term `qualifying plan' means, for a
year and subject to paragraph (4), a plan that had a quality
rating under paragraph (4) of 4 stars or higher based on the
most recent data available for such year.
``(ii) Application of increases to low enrollment plans.--
``(I) 2012.--For 2012, the term `qualifying plan' includes
an MA plan that the Secretary determines is not able to have
a quality rating under paragraph (4) because of low
enrollment.
``(II) 2013 and subsequent years.--For 2013 and subsequent
years, for purposes of determining whether an MA plan with
low enrollment (as defined by the Secretary) is included as a
qualifying plan, the Secretary shall establish a method to
apply to MA plans with low enrollment (as defined by the
Secretary) the computation of quality rating and the rating
system under paragraph (4).
``(iii) Application of increases to new plans.--
``(I) In general.--A new MA plan that meets criteria
specified by the Secretary shall be treated as a qualifying
plan, except that in applying paragraph (1), the applicable
percentage under subsection (n)(2)(B) shall be increased--
``(aa) for 2012, by 1.5 percentage points;
``(bb) for 2013, by 2.5 percentage points; and
``(cc) for 2014 or a subsequent year, by 3.5 percentage
points.
``(II) New ma plan defined.--The term `new MA plan' means,
with respect to a year, a plan offered by an organization or
sponsor that has not had a contract as a Medicare Advantage
organization in the preceding 3-year period.
``(B) Qualifying county.--The term `qualifying county'
means, for a year, a county--
``(i) that has an MA capitation rate that, in 2004, was
based on the amount specified in subsection (c)(1)(B) for a
Metropolitan Statistical Area with a population of more than
250,000;
``(ii) for which, as of December 2009, of the Medicare
Advantage eligible individuals residing in the county at
least 25 percent of such individuals were enrolled in
Medicare Advantage plans; and
``(iii) that has per capita fee-for-service spending that
is lower than the national monthly per capita cost for
expenditures for individuals enrolled under the original
medicare fee-for-service program for the year.
``(4) Quality determinations for application of increase.--
``(A) Quality determination.--The quality rating for a plan
shall be determined according to a 5-star rating system
(based on the data collected under section 1852(e)).
``(B) Plans that failed to report.--An MA plan which does
not report data that enables the Secretary to rate the plan
for purposes of this paragraph shall be counted as having a
rating of fewer than 3.5 stars.
``(5) Exception for pace plans.--This subsection shall not
apply to payments to a PACE program under section 1894.''.
(4) Determination of medicare part d low-income benchmark
premium.--Section 1860D-14(b)(2)(B)(iii) of the Social
Security Act (42 U.S.C. 1395w-114(b)(2)(B)(iii)) as amended
by section 3302 of the Patient Protection and Affordable Care
Act, is amended by striking ``, determined without regard to
any reduction in such premium as a result of any beneficiary
rebate under section 1854(b)(1)(C) or bonus payment under
section 1853(n)'' and inserting the following: ``and
determined 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, before
the application of the increase under section 1853(o) for
that plan and year involved''.
(d) Beneficiary Rebates.--Section 1854(b)(1)(C) of such Act
(42 U.S.C. 1395w-24(b)(1)(C)), as amended by section 3202(b)
of the Patient Protection and Affordable Care Act, is further
amended--
(1) in clause (i), by inserting ``(or the applicable rebate
percentage specified in clause (iii) in the case of plan
years beginning on or after January 1, 2012)'' after ``75
percent''; and
(2) by striking clause (iii), by redesignating clauses (iv)
and (v) as clauses (vii) and (viii), respectively, and by
inserting after clause (ii) the following new clauses:
``(iii) Applicable rebate percentage.--The applicable
rebate percentage specified in this clause for a plan for a
year, based on the system under section 1853(o)(4)(A), is the
sum of--
``(I) the product of the old phase-in proportion for the
year under clause (iv) and 75 percent; and
``(II) the product of the new phase-in proportion for the
year under clause (iv) and the final applicable rebate
percentage under clause (v).
``(iv) Old and new phase-in proportions.--For purposes of
clause (iv)--
``(I) for 2012, the old phase-in proportion is \2/3\ and
the new phase-in proportion is \1/3\;
``(II) for 2013, the old phase-in proportion is \1/3\ and
the new phase-in proportion is \2/3\; and
``(III) for 2014 and any subsequent year, the old phase-in
proportion is 0 and the new phase-in proportion is 1.
``(v) Final applicable rebate percentage.--Subject to
clause (vi), the final applicable rebate percentage under
this clause is--
``(I) in the case of a plan with a quality rating under
such system of at least 4.5 stars, 70 percent;
``(II) in the case of a plan with a quality rating under
such system of at least 3.5 stars and less than 4.5 stars, 65
percent; and
``(III) in the case of a plan with a quality rating under
such system of less than 3.5 stars, 50 percent.
``(vi) Treatment of low enrollment and new plans.--For
purposes of clause (v)--
``(I) for 2012, in the case of a plan described in
subclause (I) of subsection (o)(3)(A)(ii), the plan shall be
treated as having a rating of 4.5 stars; and
``(II) for 2012 or a subsequent year, in the case of a new
MA plan (as defined under subclause (III) of subsection
(o)(3)(A)(iii))) that is treated
[[Page H2158]]
as a qualifying plan pursuant to subclause (I) of such
subsection, the plan shall be treated as having a rating of
3.5 stars.''.
(e) Coding Intensity Adjustment.--Section 1853(a)(1)(C)(ii)
of such Act (42 U.S.C. 1395w-23(a)(1)(C)(ii)) is amended--
(1) in the heading, by striking ``during phaseout of budget
neutrality factor'' and inserting ``of coding adjustment'';
(2) in the matter before subclause (I), by striking
``through 2010'' and inserting ``and each subsequent year'';
and
(3) in subclause (II)--
(A) in the first sentence, by inserting ``annually'' before
``conduct an analysis'';
(B) in the second sentence--
(i) by inserting ``on a timely basis'' after ``are
incorporated''; and
(ii) by striking ``only for 2008, 2009, and 2010'' and
inserting ``for 2008 and subsequent years'';
(C) in the third sentence, by inserting ``and updated as
appropriate'' before the period at the end; and
(D) by adding at the end the following new subclauses:
``(III) In calculating each year's adjustment, the
adjustment factor shall be for 2014, not less than the
adjustment factor applied for 2010, plus 1.3 percentage
points; for each of years 2015 through 2018, not less than
the adjustment factor applied for the previous year, plus
0.25 percentage point; and for 2019 and each subsequent year,
not less than 5.7 percent.
``(IV) Such adjustment shall be applied to risk scores
until the Secretary implements risk adjustment using Medicare
Advantage diagnostic, cost, and use data.''.
(f) Repeal of Comparative Cost Adjustment 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. 1103. SAVINGS FROM LIMITS ON MA PLAN ADMINISTRATIVE
COSTS.
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
of at least .85--
``(A) the MA plan shall remit to the Secretary an amount
equal to the product of--
``(i) the total revenue of the MA plan under this part for
the contract year; and
``(ii) the difference between .85 and the medical loss
ratio;
``(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. 1104. DISPROPORTIONATE SHARE HOSPITAL (DSH) PAYMENTS.
Section 1886(r) of the Social Security Act (42 U.S.C.
1395ww(r)), as added by section 3133 of the Patient
Protection and Affordable Care Act and as amended by section
10316 of such Act, is amended--
(1) in paragraph (1), by striking ``2015'' and inserting
``2014''; and
(2) in paragraph (2)--
(A) in the matter preceding subparagraph (A), by striking
``2015'' and inserting ``2014'';
(B) in subparagraph (B)(i)--
(i) in the heading, by inserting ``2014,'' after ``years'';
(ii) in the matter preceding subclause (I), by inserting
``2014,'' after ``each of fiscal years'';
(iii) in subclause (I), by striking ``on such Act'' and
inserting ``on the Health Care and Education Reconciliation
Act of 2010''; and
(iv) in the matter following subclause (II), by striking
``minus 1.5 percentage points'' and inserting ``minus 0.1
percentage points for fiscal year 2014 and minus 0.2
percentage points for each of fiscal years 2015, 2016, and
2017''; and
(C) in subparagraph (B)(ii), in the matter following
subclause (II), by striking ``and, for each of 2018 and 2019,
minus 1.5 percentage points'' and inserting ``minus 0.2
percentage points for each of fiscal years 2018 and 2019''.
SEC. 1105. MARKET BASKET UPDATES.
(a) IPPS.--Section 1886(b)(3)(B) of the Social Security Act
(42 U.S.C. 1395ww(b)(3)(B)), as amended by sections
3401(a)(4) and 10319(a) of the Patient Protection and
Affordable Care Act, is amended--
(1) in clause (xii)--
(A) by placing the subclause (II) (inserted by section
10319(a)(3) of the Patient Protection and Affordable Care
Act) immediately after subclause (I) and, in such subclause
(II), by striking ``and'' at the end; and
(B) by striking subclause (III) and inserting the
following:
``(III) for fiscal year 2014, by 0.3 percentage point;
``(IV) for each of fiscal years 2015 and 2016, by 0.2
percentage point; and
``(V) for each of fiscal years 2017, 2018, and 2019, by
0.75 percentage point.''; and
(2) by striking clause (xiii).
(b) Long-Term Care Hospitals.--Section 1886(m)(4) of the
Social Security Act (42 U.S.C. 1395ww(m)(4)), as added by
section 3401(c) of the Patient Protection and Affordable Care
Act and amended by section 10319(b) of such Act, is amended--
(1) in subparagraph (A)--
(A) in clause (iii), by striking ``and'' at the end; and
(B) by striking clause (iv) and inserting the following:
``(iv) for rate year 2014, 0.3 percentage point;
``(v) for each of rate years 2015 and 2016, 0.2 percentage
point; and
``(vi) for each of rate years 2017, 2018, and 2019, 0.75
percentage point.'';
(2) by striking subparagraph (B); and
(3) by striking ``(4) Other adjustment.--'' and all that
follows through ``For purposes'' and inserting ``(4) Other
adjustment.--For purposes'' (and redesignating clauses (i)
through (vi) as subparagraphs (A) through (F), respectively,
with appropriate indentation).
(c) Inpatient Rehabilitation Facilities.--Section
1886(j)(3)(D) of the Social Security Act (42 U.S.C.
1395ww(j)(3)(D)), as added by section 3401(d)(2) of the
Patient Protection and Affordable Care Act and amended by
section 10319(c) of such Act, is amended--
(1) in clause (i)--
(A) by placing the subclause (II) (inserted by section
10319(c)(3) of the Patient Protection and Affordable Care
Act) immediately after subclause (I) and, in such subclause
(II), by striking ``and'' at the end; and
(B) by striking subclause (III) and inserting the
following:
``(III) for fiscal year 2014, 0.3 percentage point;
``(IV) for each of fiscal years 2015 and 2016, 0.2
percentage point; and
``(V) for each of fiscal years 2017, 2018, and 2019, 0.75
percentage point.'';
(2) by striking clause (ii); and
(3) by striking ``(D) Other adjustment.--'' and all that
follows through ``For purposes'' and inserting ``(D) Other
adjustment.--For purposes'' (and redesignating subclauses (I)
through (V) as clauses (i) through (v), respectively, with
appropriate indentation).
(d) Psychiatric Hospitals.--Section 1886(s)(3) of the
Social Security Act, as added by section 3401(f) of the
Patient Protection and Affordable Care Act and amended by
section 10319(e) of such Act, is amended--
(1) in subparagraph (A)--
(A) by placing the clause (ii) (inserted by section
10319(e)(3) of the Patient Protection and Affordable Care
Act) immediately after clause (i) and, in such clause (ii),
by striking ``and'' at the end; and
(B) by striking clause (iii) and inserting the following:
``(iii) for the rate year beginning in 2014, 0.3 percentage
point;
``(iv) for each of the rate years beginning in 2015 and
2016, 0.2 percentage point; and
``(v) for each of the rate years beginning in 2017, 2018,
and 2019, 0.75 percentage point.'';
(2) by striking subparagraph (B); and
(3) by striking ``(3) Other adjustment.--'' and all that
follows through ``For purposes'' and inserting ``(3) Other
adjustment.--For purposes'' (and redesignating clauses (i)
through (v) as subparagraphs (A) through (E), respectively,
with appropriate indentation).
(e) Outpatient Hospitals.--Section 1833(t)(3)(G) of the
Social Security Act (42 U.S.C. 1395l(t)(3)(G)), as added by
section 3401(i)(2) of the Patient Protection and Affordable
Care Act and amended by section 10319(g) of such Act, is
amended--
(1) in clause (i)--
(A) by placing the subclause (II) (inserted by section
10319(g)(3) of the Patient Protection and Affordable Care
Act) immediately after subclause (I) and, in such subclause
(II), by striking ``and'' at the end; and
(B) by striking subclause (III) and inserting the
following:
``(III) for 2014, 0.3 percentage point;
``(IV) for each of 2015 and 2016, 0.2 percentage point; and
``(V) for each of 2017, 2018, and 2019, 0.75 percentage
point.'';
(2) by striking clause (ii); and
(3) by striking ``(G) Other adjustment.--'' and all that
follows through ``For purposes'' and inserting ``(G) Other
adjustment.--For purposes'' (and redesignating subclauses (I)
through (V) as clauses (i) through (v), respectively, with
appropriate indentation).
SEC. 1106. PHYSICIAN OWNERSHIP-REFERRAL.
Section 1877(i) of the Social Security Act (42 U.S.C.
1395nn(i)), as added by section 6001(a)(3) of the Patient
Protection and Affordable Care Act and as amended by section
10601(a) of such Act, is amended--
(1) in paragraph (1)(A)(i), by striking ``August 1, 2010''
and inserting ``December 31, 2010''; and
(2) in paragraph (3)--
(A) in subparagraph (A)(i), by striking ``an applicable
hospital (as defined in subparagraph (E))'' and inserting ``a
hospital that is an applicable hospital (as defined in
subparagraph (E)) or is a high Medicaid facility described in
subparagraph (F)'';
(B) in subparagraph (C)(iii), by inserting after ``date of
enactment of this subsection'' the following: ``(or, in the
case of a hospital that did not have a provider agreement in
effect as of such date but does have such an agreement in
effect on December 31, 2010, the effective date of such
provider agreement)'';
(C) by redesignating subparagraphs (F) through (H) as
subparagraphs (G) through (I), respectively; and
(D) by inserting after subparagraph (E) the following new
subparagraph:
``(F) High medicaid facility described.--A high Medicaid
facility described in this subparagraph is a hospital that--
``(i) is not the sole hospital in a county;
``(ii) with respect to each of the 3 most recent years for
which data are available, has an annual percent of total
inpatient admissions that represent inpatient admissions
under title XIX that is estimated 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
``(iii) meets the conditions described in subparagraph
(E)(iii).''.
SEC. 1107. PAYMENT FOR IMAGING SERVICES.
Section 1848 of the Social Security Act (42 U.S.C. 1395w-
4), as amended by section 3135(a)
[[Page H2159]]
of the Patient Protection and Affordable Care Act, is
amended--
(1) in subsection (b)(4)--
(A) in subparagraph (B), by striking ``this paragraph'' and
inserting ``subparagraph (A)''; and
(B) by amending subparagraph (C) to read as follows:
``(C) Adjustment in imaging utilization rate.--With respect
to fee schedules established for 2011 and subsequent years,
in the methodology for determining practice expense relative
value units for expensive diagnostic imaging equipment under
the final rule published by the Secretary in the Federal
Register on November 25, 2009 (42 CFR 410, et al.), the
Secretary shall use a 75 percent assumption instead of the
utilization rates otherwise established in such final
rule.''; and
(2) in subsection (c)(2)(B)(v), by striking subclauses
(III), (IV), and (V) and inserting the following new
subclause:
``(III) Change in utilization rate for certain imaging
services.--Effective for fee schedules established beginning
with 2011, reduced expenditures attributable to the change in
the utilization rate applicable to 2011, as described in
subsection (b)(4)(C).''.
SEC. 1108. PE GPCI ADJUSTMENT FOR 2010.
Effective as if included in the enactment of the Patient
Protection and Affordable Care Act, section 1848(e)(1)(II)(i)
of the Social Security Act (42 U.S.C. 1395w-4(e)(1)(H)(i)),
as added by section 3102(b)(2) of the Patient Protection and
Affordable Care Act, is amended by striking ``\3/4\'' and
inserting ``\1/2\''.
SEC. 1109. PAYMENT FOR QUALIFYING HOSPITALS.
(a) In General.--From the amount available under subsection
(b), the Secretary of Health and Human Services shall provide
for a payment to qualifying hospitals (as defined in
subsection (d)) for fiscal years 2011 and 2012 of the amount
determined under subsection (c).
(b) Amounts Available.--There shall be available from the
Federal Hospital Insurance Trust Fund $400,000,000 for
payments under this section for fiscal years 2011 and 2012.
(c) Payment Amount.--The amount of payment under this
section for a qualifying hospital shall be determined, in a
manner consistent with the amount available under subsection
(b), in proportion to the portion of the amount of the
aggregate payments under section 1886(d) of the Social
Security Act to the hospital for fiscal year 2009 bears to
the sum of all such payments to all qualifying hospitals for
such fiscal year.
(d) Qualifying Hospital Defined.--In this section, the term
``qualifying hospital'' means a subsection (d) hospital (as
defined for purposes of section 1886(d) of the Social
Security Act) that is located in a county that ranks, based
upon its ranking in age, sex, and race adjusted spending for
benefits under parts A and B under title XVIII of such Act
per enrollee, within the lowest quartile of such counties in
the United States.
Subtitle C--Medicaid
SEC. 1201. FEDERAL FUNDING FOR STATES.
Section 1905 of the Social Security Act (42 U.S.C. 1396d),
as amended by sections 2001(a)(3) and 10201(c) of the Patient
Protection and Affordable Care Act, is amended--
(1) in subsection (y)--
(A) by redesignating subclause (II) of paragraph (1)(B)(ii)
as paragraph (5) of subsection (z) and realigning the left
margins accordingly; and
(B) by striking paragraph (1) and inserting the following:
``(1) Amount of increase.--Notwithstanding subsection (b),
the Federal medical assistance percentage for a State that is
one of the 50 States or the District of Columbia, with
respect to amounts expended by such State for medical
assistance for newly eligible individuals described in
subclause (VIII) of section 1902(a)(10)(A)(i), shall be equal
to--
``(A) 100 percent for calendar quarters in 2014, 2015, and
2016;
``(B) 95 percent for calendar quarters in 2017;
``(C) 94 percent for calendar quarters in 2018;
``(D) 93 percent for calendar quarters in 2019; and
``(E) 90 percent for calendar quarters in 2020 and each
year thereafter.''; and
(2) in subsection (z)--
(A) in paragraph (1), by striking ``September 30, 2019''
and inserting ``December 31, 2015'' and by striking
``subsection (y)(1)(B)(ii)(II)'' and inserting ``paragraph
(3)'';
(B) by striking paragraphs (2) through (4) and inserting
the following:
``(2)(A) For calendar quarters in 2014 and each year
thereafter, the Federal medical assistance percentage
otherwise determined under subsection (b) for an expansion
State described in paragraph (3) with respect to medical
assistance for individuals described in section
1902(a)(10)(A)(i)(VIII) who are nonpregnant childless adults
with respect to whom the State may require enrollment in
benchmark coverage under section 1937 shall be equal to the
percent specified in subparagraph (B)(i) for such year.
``(B)(i) The percent specified in this subparagraph for a
State for a year is equal to the Federal medical assistance
percentage (as defined in the first sentence of subsection
(b)) for the State increased by a number of percentage points
equal to the transition percentage (specified in clause (ii)
for the year) of the number of percentage points by which--
``(I) such Federal medical assistance percentage for the
State, is less than
``(II) the percent specified in subsection (y)(1) for the
year.
``(ii) The transition percentage specified in this clause
for--
``(I) 2014 is 50 percent;
``(II) 2015 is 60 percent;
``(III) 2016 is 70 percent;
``(IV) 2017 is 80 percent;
``(V) 2018 is 90 percent; and
``(VI) 2019 and each subsequent year is 100 percent.''; and
(C) by redesignating paragraph (5) (as added by paragraph
(1)(A) of this section) as paragraph (3), realigning the left
margins to align with paragraph (2), and striking the heading
and all that follows through ``a State is'' and inserting ``A
State is''.
SEC. 1202. PAYMENTS TO PRIMARY CARE PHYSICIANS.
(a) In General.--
(1) Fee-for-service payments.--Section 1902 of the Social
Security Act (42 U.S.C. 1396a), as amended by section
2303(a)(2) of the Patient Protection and Affordable Care Act,
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 (jj)) furnished in 2013 and 2014 by a physician
with a primary specialty designation of family medicine,
general internal medicine, or pediatric medicine at a rate
not less than 100 percent of the payment rate that applies to
such services and physician under part B of title XVIII (or,
if greater, the payment rate that would be applicable under
such part if the conversion factor under section 1848(d) for
the year involved were the conversion factor under such
section for 2009);''; and
(B) by adding at the end the following new subsection:
``(jj) Primary Care Services Defined.--For purposes of
subsection (a)(13)(C), the term `primary care services'
means--
``(1) evaluation and management services that are procedure
codes (for services covered under title XVIII) for services
in the category designated Evaluation and Management in the
Healthcare Common Procedure Coding System (established by the
Secretary under section 1848(c)(5) as of December 31, 2009,
and as subsequently modified); and
``(2) services related to immunization administration for
vaccines and toxoids for which CPT codes 90465, 90466, 90467,
90468, 90471, 90472, 90473, or 90474 (as subsequently
modified) apply under such System.''.
(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
of the Social Security Act, as amended by section 1004(b) of
this Act and section 10201(c)(6) of the Patient Protection
and Affordable Care Act, is amended by adding at the end the
following new subsection:
``(dd) Increased FMAP for Additional Expenditures for
Primary Care Services.--Notwithstanding subsection (b), with
respect to the portion of the amounts expended for medical
assistance for services described in section 1902(a)(13)(C)
furnished on or after January 1, 2013, and before January 1,
2015, 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 July 1, 2009, the Federal
medical assistance percentage for a State that is one of the
50 States or the District of Columbia shall be equal to 100
percent. The preceding sentence does not prohibit the payment
of Federal financial participation based on the Federal
medical assistance percentage for amounts in excess of those
specified in such sentence.''.
SEC. 1203. DISPROPORTIONATE SHARE HOSPITAL PAYMENTS.
(a) In General.--Section 1923(f) of the Social Security Act
(42 U.S.C. 1396r-4(f)), as amended by sections 2551(a)(4) and
10201(e)(1) of the Patient Protection and Affordable Care
Act, is amended--
(1) in paragraph (6)(B)(iii), in the matter preceding
subclause (I), by striking ``or paragraph (7)''; and
(2) by striking paragraph (7) and inserting the following:
``(7) Medicaid dsh reductions.--
``(A) Reductions.--
``(i) In general.--For each of fiscal years 2014 through
2020 the Secretary shall effect the following reductions:
``(I) Reduction in dsh allotments.--The Secretary shall
reduce DSH allotments to States in the amount specified under
the DSH health reform methodology under subparagraph (B) for
the State for the fiscal year.
``(II) Reductions in payments.--The Secretary shall reduce
payments to States under section 1903(a) for each calendar
quarter in the fiscal year, in the manner specified in clause
(iii), in an amount equal to \1/4\ of the DSH allotment
reduction under subclause (I) for the State for the fiscal
year.
``(ii) Aggregate reductions.--The aggregate reductions in
DSH allotments for all States under clause (i)(I) shall be
equal to--
``(I) $500,000,000 for fiscal year 2014;
``(II) $600,000,000 for fiscal year 2015;
``(III) $600,000,000 for fiscal year 2016;
``(IV) $1,800,000,000 for fiscal year 2017;
``(V) $5,000,000,000 for fiscal year 2018;
``(VI) $5,600,000,000 for fiscal year 2019; and
``(VII) $4,000,000,000 for fiscal year 2020.
The Secretary shall distribute such aggregate reductions
among States in accordance with subparagraph (B).
[[Page H2160]]
``(iii) Manner of payment reduction.--The amount of the
payment reduction under clause (i)(II) 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 spending under section 1903(d)(2).
Such a disallowance is not subject to a reconsideration under
subsections (d) and (e) of section 1116.
``(iv) Definition.--In this paragraph, the term `State'
means the 50 States and the District of Columbia.
``(B) DSH health reform methodology.--The Secretary shall
carry out subparagraph (A) through use of a DSH Health Reform
methodology that meets the following requirements:
``(i) The methodology imposes the largest percentage
reductions on the States that--
``(I) have the lowest percentages of uninsured individuals
(determined on the basis of data from the Bureau of the
Census, audited hospital cost reports, and other information
likely to yield accurate data) during the most recent year
for which such data are available; or
``(II) do not target their DSH payments on--
``(aa) hospitals with high volumes of Medicaid inpatients
(as defined in subsection (b)(1)(A)); and
``(bb) hospitals that have high levels of uncompensated
care (excluding bad debt).
``(ii) The methodology imposes a smaller percentage
reduction on low DSH States described in paragraph (5)(B).
``(iii) The methodology takes into account the extent to
which the DSH allotment for a State was included in the
budget neutrality calculation for a coverage expansion
approved under section 1115 as of July 31, 2009.''.
(b) Extension of DSH Allotment.--Section 1923(f)(6)(A) of
the Social Security Act (42 U.S.C. 1396r-4(f)(6)(A)) is
amended by adding at the end the following:
``(v) Allotment for 2d, 3rd, and 4th quarters of fiscal
year 2012 and for fiscal year 2013.--Notwithstanding the
table set forth in paragraph (2):
``(I) 2d, 3rd, and 4th quarters of fiscal year 2012.--In
the case of a State that has a DSH allotment of $0 for the
2d, 3rd, and 4th quarters of fiscal year 2012, the DSH
allotment shall be $47,200,000 for such quarters.
``(II) Fiscal year 2013.--In the case of a State that has a
DSH allotment of $0 for fiscal year 2013, the DSH allotment
shall be $53,100,000 for such fiscal year.''.
SEC. 1204. FUNDING FOR THE TERRITORIES.
(a) In General.--Part III of subtitle D of title I of the
Patient Protection and Affordable Care Act, as amended by
section 10104(m) of such Act, is amended by inserting after
section 1322 the following section:
``SEC. 1323. FUNDING FOR THE TERRITORIES.
``(a) In General.--A territory that--
``(1) elects consistent with subsection (b) to establish an
Exchange in accordance with part II of this subtitle and
establishes such an Exchange in accordance with such part
shall be treated as a State for purposes of such part and
shall be entitled to payment from the amount allocated to the
territory under subsection (c); or
``(2) does not make such election shall be entitled to an
increase in the dollar limitation applicable to the territory
under subsections (f) and (g) of section 1108 of the Social
Security Act (42 U.S.C. 1308) for such period in such amount
for such territory and such increase shall not be taken into
account in computing any other amount under such subsections.
``(b) Terms and Conditions.--An election under subsection
(a)(1) shall--
``(1) not be effective unless the election is consistent
with section 1321 and is received not later than October 1,
2013; and''.
``(2) be contingent upon entering into an agreement between
the territory and the Secretary that requires that--
``(A) funds provided under the agreement shall be used only
to provide premium and cost-sharing assistance to residents
of the territory obtaining health insurance coverage through
the Exchange; and
``(B) the premium and cost-sharing assistance provided
under such agreement shall be structured in such a manner so
as to prevent any gap in assistance for individuals between
the income level at which medical assistance is available
through the territory's Medicaid plan under title XIX of the
Social Security Act and the income level at which premium and
cost-sharing assistance is available under the agreement.
``(c) Appropriation and Allocation.--
``(1) Appropriation.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated for purposes of
payment pursuant to subsection (a) $1,000,000,000, to be
available during the period beginning with 2014 and ending
with 2019.
``(2) Allocation.--The Secretary shall allocate the amount
appropriated under paragraph (1) among the territories for
purposes of carrying out this section as follows:
``(A) For Puerto Rico, $925,000,000.
``(B) For another territory, the portion of $75,000,000
specified by the Secretary.''.
(b) Medicaid Funding.--
(1) Increase in funding caps.--Section 1108(g) of the
Social Security Act (42 U.S.C. 1308(g)), as amended by
section 2005(a) of the Patient Protection and Affordable Care
Act, is amended--
(A) in paragraph (2), by inserting ``and section 1323(a)(2)
of the Patient Protection and Affordable Care Act'' after
``subject to''; and
(B) by striking paragraph (5) and inserting the following:
``(5) Additional increase.--The Secretary shall increase
the amounts otherwise determined under this subsection for
Puerto Rico, the Virgin Islands, Guam, the Northern Mariana
Islands, and American Samoa (after the application of
subsection (f) and the preceding paragraphs of this
subsection) for the period beginning July 1, 2011, and ending
on September 30, 2019, by such amounts that the total
additional payments under title XIX to such territories
equals $6,300,000,000 for such period. The Secretary shall
increase such amounts in proportion to the amounts applicable
to such territories under this subsection and subsection (f)
on the date of enactment of this paragraph.''.
(2) Disregard of payments; increased fmap.--Section 2005 of
the Patient Protection and Affordable Care Act is amended--
(A) by repealing subsection (b) (and the amendments made by
that subsection) and section 1108(g)(4) of the Social
Security Act shall be applied as if such amendments had never
been enacted; and
(B) in subsection (c)(2), by striking ``January'' and
inserting ``July''.
SEC. 1205. DELAY IN COMMUNITY FIRST CHOICE OPTION.
Section 1915(k)(1) of the Social Security Act (42 U.S.C.
1396n(k)), as added by section 2401 of the Patient Protection
and Affordable Care Act, is amended by striking ``October 1,
2010'' and inserting ``October 1, 2011''.
SEC. 1206. DRUG REBATES FOR NEW FORMULATIONS OF EXISTING
DRUGS.
(a) Treatment of New Formulations.--Subparagraph (C) of
section 1927(c)(2) of the Social Security Act (42 U.S.C.
1396r-8(c)(2)), as added by section 2501(d) of the Patient
Protection and Affordable Care Act, is amended to read as
follows:
``(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.''.
(b) Effective Date.--The amendment made by subsection (a)
shall take effect as if included in the enactment of the
Patient Protection and Affordable Care Act.
Subtitle D--Reducing Fraud, Waste, and Abuse
SEC. 1301. COMMUNITY MENTAL HEALTH CENTERS.
(a) In General.--Section 1861(ff)(3)(B) of the Social
Security Act (42 U.S.C. 1395x(ff)(3)(B)) is amended--
(1) in clause (ii), by striking ``and'' at the end;
(2) by redesignating clause (iii) as clause (iv); and
(3) by inserting after clause (ii) the following:
``(iii) provides at least 40 percent of its services to
individuals who are not eligible for benefits under this
title; and''.
(b) Restriction.--Section 1861(ff)(3)(A) of such Act (42
U.S.C. 1395x(ff)(3)(A)) is amended by inserting ``other than
in an individual's home or in an inpatient or residential
setting'' before the period.
(c) Effective Date.--The amendments made by this section
shall apply to items and services furnished on or after the
first day of the first calendar quarter that begins at least
12 months after the date of the enactment of this Act.
SEC. 1302. MEDICARE PREPAYMENT MEDICAL REVIEW LIMITATIONS .
Section 1874A(h) of the Social Security Act (42 U.S.C.
1395w-3a(h)) is repealed.
SEC. 1303. FUNDING TO FIGHT FRAUD, WASTE, AND ABUSE.
(a) Funding to Fight Fraud, Waste, and Abuse.--
(1) In general.--Section 1817(k) of the Social Security Act
(42 U.S.C. 1395i(k)), as amended by section 6402(i) of the
Patient Protection and Affordable Care Act, is further
amended--
(A) by adding at the end the following new paragraph:
``(8) Additional funding.--
``(A) In general.--In addition to the funds otherwise
appropriated to the Account from the Trust Fund under
paragraphs (3)(C) and (4)(A) and for purposes described in
paragraphs (3)(C) and (4)(A), there are hereby appropriated
to such Account from such Trust Fund the following additional
amounts:
``(i) For fiscal year 2011, $95,000,000.
``(ii) For fiscal year 2012, $55,000,000.
``(iii) For each of fiscal years 2013 and 2014,
$30,000,000.
``(iv) For each of fiscal years 2015 and 2016, $20,000,000.
``(B) Allocation.--The funds appropriated under this
paragraph shall be allocated in the same proportion as the
total funding appropriated with respect to paragraphs (3)(A)
and (4)(A) was allocated with respect to fiscal year 2010,
and shall be available without further appropriation until
expended.''; and
(B) in paragraph (4)(A), by inserting ``for activities
described in paragraph (3)(C) and'' after ``necessary''.
(b) Medicaid Integrity Program.--Section 1936(e)(1) of such
Act (42 U.S.C. 1396-u6(e)(1)) is amended--
(1) in subparagraph (B), by striking at the end ``and'';
(2) in subparagraph (C)--
[[Page H2161]]
(A) by striking ``for each fiscal year thereafter'' and
inserting ``for each of fiscal years 2009 and 2010''; and
(B) by striking the period and inserting ``; and''; and
(3) by adding at the end the following new subparagraph:
``(D) for each fiscal year after fiscal year 2010, the
amount appropriated under this paragraph for the previous
fiscal year, increased by the percentage increase in the
consumer price index for all urban consumers (all items;
United States city average) over the previous year.''.
SEC. 1304. 90-DAY PERIOD OF ENHANCED OVERSIGHT FOR INITIAL
CLAIMS OF DME SUPPLIERS.
Section 1866(j), as amended by section 6401 of the Patient
Protection and Affordable Care Act, is further amended--
(1) by redesignating paragraphs (4) through (7) as
paragraphs (5) through (8), respectively; and
(2) by inserting after paragraph (3) the following new
paragraph:
``(4) 90-day period of enhanced oversight for initial
claims of dme suppliers.--For periods beginning after January
1, 2011, if the Secretary determines 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 sections 1816(c),
1842(c), and 1869(a)(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.''.
Subtitle E--Provisions Relating to Revenue
SEC. 1401. HIGH-COST PLAN EXCISE TAX.
(a) In General.--Section 4980I of the Internal Revenue Code
of 1986, as added by section 9001 of the Patient Protection
and Affordable Care Act and amended by section 10901 of such
Act, is amended--
(1) in subsection (b)(3)(B)--
(A) by striking ``The annual'' and inserting the following:
``(i) In general.--Except as provided in clause (ii), the
annual'', and
(B) by adding at the end the following new clause:
``(ii) Multiemployer plan coverage.--Any coverage provided
under a multiemployer plan (as defined in section 414(f))
shall be treated as coverage other than self-only
coverage.'',
(2) in subsection (b)(3)(C)--
(A) by striking ``Except as provided in subparagraph (D)--
''
(B) in clause (i)--
(i) by striking ``2013'' each place it appears in the
heading and the text and inserting ``2018'',
(ii) by striking ``$8,500'' in subclause (I) and inserting
``$10,200 multiplied by the health cost adjustment percentage
(determined by only taking into account self-only
coverage)'', and
(iii) by striking ``$23,000'' in subclause (II) and
inserting ``$27,500 multiplied by the health cost adjustment
percentage (determined by only taking into account coverage
other than self-only coverage)'',
(C) by redesignating clauses (ii) and (iii) as clauses (iv)
and (v), respectively, and by inserting after clause (i) the
following new clauses:
``(ii) Health cost adjustment percentage.--For purposes of
clause (i), the health cost adjustment percentage is equal to
100 percent plus the excess (if any) of--
``(I) the percentage by which the per employee cost for
providing coverage under the Blue Cross/Blue Shield standard
benefit option under the Federal Employees Health Benefits
Plan for plan year 2018 (determined by using the benefit
package for such coverage in 2010) exceeds such cost for plan
year 2010, over
``(II) 55 percent.
``(iii) Age and gender adjustment.--
``(I) In general.--The amount determined under subclause
(I) or (II) of clause (i), whichever is applicable, for any
taxable period shall be increased by the amount determined
under subclause (II).
``(II) Amount determined.--The amount determined under this
subclause is an amount equal to the excess (if any) of--
``(aa) the premium cost of the Blue Cross/Blue Shield
standard benefit option under the Federal Employees Health
Benefits Plan for the type of coverage provided such
individual in such taxable period if priced for the age and
gender characteristics of all employees of the individual's
employer, over
``(bb) that premium cost for the provision of such coverage
under such option in such taxable period if priced for the
age and gender characteristics of the national workforce.''.
(D) in clause (iv), as redesignated by subparagraph (C)--
(i) by inserting ``covered by the plan'' after ``whose
employees'', and
(ii) by striking subclauses (I) and (II) and inserting the
following:
``(I) the dollar amount in clause (i)(I) shall be increased
by $1,650, and
``(II) the dollar amount in clause (i)(II) shall be
increased by $3,450,'', and
(E) in clause (v), as redesignated by subparagraph (C)--
(i) by striking ``2013'' and inserting ``2018'',
(ii) by striking ``clauses (i) and (ii)'' and inserting
``clauses (i) (after the application of clause (ii)) and
(iv)'', and
(iii) by inserting ``in the case of determinations for
calendar years beginning before 2020'' after ``1 percentage
point'' in subclause (II) thereof,
(3) by striking subparagraph (D) of subsection (b)(3),
(4) in subsection (d)(1)(B), by redesignating clause (ii)
as clause (iii) and by inserting after clause (i) the
following new clause:
``(ii) any coverage under a separate policy, certificate,
or contract of insurance which provides benefits
substantially all of which are for treatment of the mouth
(including any organ or structure within the mouth) or for
treatment of the eye, or'', and
(5) in subsection (d), by adding at the end the following
new paragraph:
``(3) Employee.--The term `employee' includes any former
employee, surviving spouse, or other primary insured
individual.''.
(b) Effective Dates.--
(1) Section 9001(c) of the Patient Protection and
Affordable Care Act is amended by striking ``2012'' and
inserting ``2017''.
(2) Section 10901(c) of the Patient Protection and
Affordable Care Act is amended by striking ``2012'' and
inserting ``2017''.
SEC. 1402. UNEARNED INCOME MEDICARE CONTRIBUTION.
(a) Investment Income.--
(1) In general.--Subtitle A of the Internal Revenue Code of
1986 is amended by inserting after chapter 2 the following
new chapter:
``CHAPTER 2A--UNEARNED INCOME MEDICARE CONTRIBUTION
``Sec. 1411. Imposition of tax.
``SEC. 1411. IMPOSITION OF TAX.
``(a) In General.--Except as provided in subsection (e)--
``(1) Application to individuals.--In the case of an
individual, there is hereby imposed (in addition to any other
tax imposed by this subtitle) for each taxable year a tax
equal to 3.8 percent of the lesser of--
``(A) net investment income for such taxable year, or
``(B) the excess (if any) of--
``(i) the modified adjusted gross income for such taxable
year, over
``(ii) the threshold amount.
``(2) Application to estates and trusts.--In the case of an
estate or trust, there is hereby imposed (in addition to any
other tax imposed by this subtitle) for each taxable year a
tax of 3.8 percent of the lesser of--
``(A) the undistributed net investment income for such
taxable year, or
``(B) the excess (if any) of--
``(i) the adjusted gross income (as defined in section
67(e)) for such taxable year, over
``(ii) the dollar amount at which the highest tax bracket
in section 1(e) begins for such taxable year.
``(b) Threshold Amount.--For purposes of this chapter, the
term `threshold amount' means--
``(1) in the case of a taxpayer making a joint return under
section 6013 or a surviving spouse (as defined in section
2(a)), $250,000,
``(2) in the case of a married taxpayer (as defined in
section 7703) filing a separate return, \1/2\ of the dollar
amount determined under paragraph (1), and
``(3) in any other case, $200,000.
``(c) Net Investment Income.--For purposes of this
chapter--
``(1) In general.--The term `net investment income' means
the excess (if any) of--
``(A) the sum of--
``(i) gross income from interest, dividends, annuities,
royalties, and rents, other than such income which is derived
in the ordinary course of a trade or business not described
in paragraph (2),
``(ii) other gross income derived from a trade or business
described in paragraph (2), and
``(iii) net gain (to the extent taken into account in
computing taxable income) attributable to the disposition of
property other than property held in a trade or business not
described in paragraph (2), over
``(B) the deductions allowed by this subtitle which are
properly allocable to such gross income or net gain.
``(2) Trades and businesses to which tax applies.--A trade
or business is described in this paragraph if such trade or
business is--
``(A) a passive activity (within the meaning of section
469) with respect to the taxpayer, or
``(B) a trade or business of trading in financial
instruments or commodities (as defined in section 475(e)(2)).
``(3) Income on investment of working capital subject to
tax.--A rule similar to the rule of section 469(e)(1)(B)
shall apply for purposes of this subsection.
``(4) Exception for certain active interests in
partnerships and s corporations.--In the case of a
disposition of an interest in a partnership or S
corporation--
``(A) gain from such disposition shall be taken into
account under clause (iii) of paragraph (1)(A) only to the
extent of the net gain which would be so taken into account
by the transferor if all property of the partnership or S
corporation were sold for fair market value immediately
before the disposition of such interest, and
``(B) a rule similar to the rule of subparagraph (A) shall
apply to a loss from such disposition.
``(5) Exception for distributions from qualified plans.--
The term `net investment income' shall not include any
distribution from a plan or arrangement described in section
401(a), 403(a), 403(b), 408, 408A, or 457(b).
``(6) Special rule.--Net investment income shall not
include any item taken into account in determining self-
employment income for such taxable year on which a tax is
imposed by section 1401(b).
``(d) Modified Adjusted Gross Income.--For purposes of this
chapter, the term `modified adjusted gross income' means
adjusted gross income increased by the excess of--
``(1) the amount excluded from gross income under section
911(a)(1), over
[[Page H2162]]
``(2) the amount of any deductions (taken into account in
computing adjusted gross income) or exclusions disallowed
under section 911(d)(6) with respect to the amounts described
in paragraph (1).
``(e) Nonapplication of Section.--This section shall not
apply to--
``(1) a nonresident alien, or
``(2) a trust all of the unexpired interests in which are
devoted to one or more of the purposes described in section
170(c)(2)(B).''.
(2) Estimated taxes.--Section 6654 of the Internal Revenue
Code of 1986 is amended--
(A) in subsection (a), by striking ``and the tax under
chapter 2'' and inserting ``the tax under chapter 2, and the
tax under chapter 2A'', and
(B) in subsection (f)--
(i) by striking ``minus'' at the end of paragraph (2) and
inserting ``plus'', and
(ii) by redesignating paragraph (3) as paragraph (4) and
inserting after paragraph (2) the following new paragraph:
``(3) the taxes imposed by chapter 2A, minus''.
(3) Clerical amendment.--The table of chapters for subtitle
A of chapter 1 of the Internal Revenue Code of 1986 is
amended by inserting after the item relating to chapter 2 the
following new item:
``Chapter 2A--Unearned Income Medicare Contribution''.
(4) Effective dates.--The amendments made by this
subsection shall apply to taxable years beginning after
December 31, 2012.
(b) Earned Income.--
(1) Threshold.--
(A) FICA.--Paragraph (2) of section 3101(b) of the Internal
Revenue Code of 1986, as added by section 9015 of the Patient
Protection and Affordable Care Act and amended by section
10906 of such Act, is amended by striking ``and'' at the end
of subparagraph (A), by redesignating subparagraph (B) as
subparagraph (C), and by inserting after subparagraph (A) the
following new subparagraph:
``(B) in the case of a married taxpayer (as defined in
section 7703) filing a separate return, \1/2\ of the dollar
amount determined under subparagraph (A), and''.
(B) SECA.--Section 1401(b)(2) of the Internal Revenue Code
of 1986, as added by section 9015 of the Patient Protection
and Affordable Care Act and amended by section 10906 of such
Act, is amended--
(i) in subparagraph (A), by striking ``and'' at the end of
clause (i), by redesignating clause (ii) as clause (iii), and
by inserting after clause (i) the following new clause:
``(ii) in the case of a married taxpayer (as defined in
section 7703) filing a separate return, \1/2\ of the dollar
amount determined under clause (i), and'', and
(ii) in subparagraph (B), by striking ``under clauses (i)
and (ii)'' and inserting ``under clause (i), (ii), or (iii)
(whichever is applicable)''.
(2) Estimated taxes.--Section 6654 of the Internal Revenue
Code of 1986 is amended by redesignating subsection (m) as
subsection (n) and by inserting after subsection (l) the
following new subsection:
``(m) Special Rule for Medicare Tax.--For purposes of this
section, the tax imposed under section 3101(b)(2) (to the
extent not withheld) shall be treated as a tax imposed under
chapter 2.''.
(3) Effective date.--The amendments made by this subsection
shall apply with respect to remuneration received, and
taxable years beginning after, December 31, 2012.
SEC. 1403. DELAY OF LIMITATION ON HEALTH FLEXIBLE SPENDING
ARRANGEMENTS UNDER CAFETERIA PLANS.
(a) In General.--Section 10902(b) of the Patient Protection
and Affordable Care Act is amended by striking ``December 31,
2010'' and inserting ``December 31, 2012''.
(b) Inflation Adjustment.--Paragraph (2) of section 125(i)
of the Internal Revenue Code of 1986, as added by section
9005 of the Patient Protection and Affordable Care Act and
amended by section 10902 of such Act, is amended--
(1) in the matter preceding subparagraph (A), by striking
``December 31, 2011'' and inserting ``December 31, 2013'',
and
(2) in subparagraph (B), by striking ``2010'' and inserting
``2012''.
SEC. 1404. BRAND NAME PHARMACEUTICALS.
(a) In General.--Section 9008 of the Patient Protection and
Affordable Care Act is amended--
(1) in subsection (a)(1), by striking ``2009'' and
inserting ``2010'',
(2) in subsection (b)--
(A) by striking ``$2,300,000,000'' in paragraph (1) and
inserting ``the applicable amount'', and
(B) by adding at the end the following new paragraph:
``(4) Applicable amount.--For purposes of paragraph (1),
the applicable amount shall be determined in accordance with
the following table:
``Calendar year Applicable amount
2011.................................... $2,500,000,000
2012.................................... $2,800,000,000
2013.................................... $2,800,000,000
2014.................................... $3,000,000,000
2015.................................... $3,000,000,000
2016.................................... $3,000,000,000
2017.................................... $4,000,000,000.
2018.................................... $4,100,000,000
2019 and thereafter..................... $2,800,000,000.'',
(3) in subsection (d), by adding at the end the following
new paragraph:
``(3) Joint and several liability.--If more than one person
is liable for payment of the fee under subsection (a) with
respect to a single covered entity by reason of the
application of paragraph (2), all such persons shall be
jointly and severally liable for payment of such fee.'', and
(4) by striking subsection (j) and inserting the following
new subsection:
``(j) Effective Date.--This section shall apply to calendar
years beginning after December 31, 2010.''.
(b) Effective Date.--The amendments made by this section
shall take effect as if included in section 9008 of the
Patient Protection and Affordable Care Act.
SEC. 1405. EXCISE TAX ON MEDICAL DEVICE MANUFACTURERS.
(a) In General.--Chapter 32 of the Internal Revenue Code of
1986 is amended--
(1) by inserting after subchapter D the following new
subchapter:
``Subchapter E--Medical Devices
``Sec. 4191. Medical devices.
``SEC. 4191. MEDICAL DEVICES.
``(a) In General.--There is hereby imposed on the sale of
any taxable medical device by the manufacturer, producer, or
importer a tax equal to 2.3 percent of the price for which so
sold.
``(b) Taxable Medical Device.--For purposes of this
section--
``(1) In general.--The term `taxable medical device' means
any device (as defined in section 201(h) of the Federal Food,
Drug, and Cosmetic Act) intended for humans.
``(2) Exemptions.--Such term shall not include--
``(A) eyeglasses,
``(B) contact lenses,
``(C) hearing aids, and
``(D) any other medical device determined by the Secretary
to be of a type which is generally purchased by the general
public at retail for individual use.'', and
(2) by inserting after the item relating to subchapter D in
the table of subchapters for such chapter the following new
item:
``subchapter e. medical devices.''.
(b) Certain Exemptions Not to Apply.--
(1) Section 4221(a) of the Internal Revenue Code of 1986 is
amended by adding at the end the following new sentence: ``In
the case of the tax imposed by section 4191, paragraphs (3),
(4), (5), and (6) shall not apply.''.
(2) Section 6416(b)(2) of such Code is amended by adding at
the end the following: ``In the case of the tax imposed by
section 4191, subparagraphs (B), (C), (D), and (E) shall not
apply.''.
(c) Effective Date.--The amendments made by this section
shall apply to sales after December 31, 2012.
(d) Repeal of Section 9009 of the Patient Protection and
Affordable Care Act.--Section 9009 of the Patient Protection
and Affordable Care Act, as amended by section 10904 of such
Act, is repealed effective as of the date of enactment of
that Act.
SEC. 1406. HEALTH INSURANCE PROVIDERS.
(a) In General.--Section 9010 of the Patient Protection and
Affordable Care Act, as amended by section 10905 of such Act,
is amended--
(1) in subsection (a)(1), by striking ``2010'' and
inserting ``2013'',
(2) in subsection (b)(2)--
(A) by striking ``For purposes of paragraph (1), the net
premiums'' and inserting ``For purposes of paragraph (1)--
``(A) In general.--The net premiums'', and
(B) by adding at the end the following subparagraph:
``(B) Partial exclusion for certain exempt activities.--
After the application of subparagraph (A), only 50 percent of
the remaining net premiums written with respect to health
insurance for any United States health risk that are
attributable to the activities (other than activities of an
unrelated trade or business as defined in section 513 of the
Internal Revenue Code of 1986) of any covered entity
qualifying under paragraph (3), (4), (26), or (29) of section
501(c) of such Code and exempt from tax under section 501(a)
of such Code shall be taken into account.'',
(3) in subsection (c)--
(A) by inserting ``during the calendar year in which the
fee under this section is due'' in paragraph (1) after
``risk'',
(B) in paragraph (2), by striking subparagraphs (C), (D),
and (E) and inserting the following new subparagraphs:
``(C) any entity--
``(i) which is incorporated as a nonprofit corporation
under a State law,
``(ii) no part of the net earnings of which inures to the
benefit of any private shareholder or individual, no
substantial part of the activities of which is carrying on
propaganda, or otherwise attempting, to influence legislation
(except as otherwise provided in section 501(h) of the
Internal Revenue Code of 1986), and which does not
participate in, or intervene in (including the publishing or
distributing of statements), any political campaign on behalf
of (or in opposition to) any candidate for public office, and
``(iii) more than 80 percent of the gross revenues of which
is received from government programs that target low-income,
elderly, or disabled populations under titles XVIII, XIX, and
XXI of the Social Security Act, and
``(D) any entity which is described in section 501(c)(9) of
such Code and which is established by an entity (other than
by an employer or employers) for purposes of providing health
care benefits.'',
(C) in paragraph (3)(A), by striking ``subparagraph
(C)(i)(I), (D)(i)(I), or (E)(i)'' and inserting
``subparagraph (C) or (D)'', and
(D) by adding at the end the following new paragraph:
``(4) Joint and several liability.--If more than one person
is liable for payment of the fee under subsection (a) with
respect to a single covered entity by reason of the
application of paragraph (3), all such persons shall be
jointly and severally liable for payment of such fee.'',
(4) by striking subsection (e) and inserting the following:
``(e) Applicable Amount.--For purposes of subsection
(b)(1)--
[[Page H2163]]
``(1) Years before 2019.--In the case of calendar years
beginning before 2019, the applicable amount shall be
determined in accordance with the following table:
``Calendar year Applicable amount
2014.................................... $8,000,000,000
2015.................................... $11,300,000,000
2016.................................... $11,300,000,000
2017.................................... $13,900,000,000
2018.................................... $14,300,000,000.
``(2) Years after 2018.--In the case of any calendar year
beginning after 2018, the applicable amount shall be the
applicable amount for the preceding calendar year increased
by the rate of premium growth (within the meaning of section
36B(b)(3)(A)(ii) of the Internal Revenue Code of 1986) for
such preceding calendar year.'',
(5) in subsection (g), by adding at the end the following
new paragraphs:
``(3) Accuracy-related penalty.--
``(A) In general.--In the case of any understatement of a
covered entity's net premiums written with respect to health
insurance for any United States health risk for any calendar
year, there shall be paid by the covered entity making such
understatement, an amount equal to the excess of--
``(i) the amount of the covered entity's fee under this
section for the calendar year the Secretary determines should
have been paid in the absence of any such understatement,
over
``(ii) the amount of such fee the Secretary determined
based on such understatement.
``(B) Understatement.--For purposes of this paragraph, an
understatement of a covered entity's net premiums written
with respect to health insurance for any United States health
risk for any calendar year is the difference between the
amount of such net premiums written as reported on the return
filed by the covered entity under paragraph (1) and the
amount of such net premiums written that should have been
reported on such return.
``(C) Treatment of penalty.--The penalty imposed under
subparagraph (A) shall be subject to the provisions of
subtitle F of the Internal Revenue Code of 1986 that apply to
assessable penalties imposed under chapter 68 of such Code.
``(4) Treatment of information.--Section 6103 of the
Internal Revenue Code of 1986 shall not apply to any
information reported under this subsection.'', and
(6) by striking subsection (j) and inserting the following
new subsection:
``(j) Effective Date.--This section shall apply to calendar
years beginning after December 31, 2013.''.
(b) Effective Date.--The amendments made by this section
shall take effect as if included in section 9010 of the
Patient Protection and Affordable Care Act.
SEC. 1407. DELAY OF ELIMINATION OF DEDUCTION FOR EXPENSES
ALLOCABLE TO MEDICARE PART D SUBSIDY.
Section 9012(b) of the Patient Protection and Affordable
Care Act is amended by striking ``2010'' and inserting
``2012''.
SEC. 1408. ELIMINATION OF UNINTENDED APPLICATION OF
CELLULOSIC BIOFUEL PRODUCER CREDIT.
(a) In General.--Section 40(b)(6)(E) 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 on or after January 1,
2010.
SEC. 1409. CODIFICATION OF ECONOMIC SUBSTANCE DOCTRINE AND
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 shall be taken into account as expenses
in determining pre-tax profit under subparagraph (A). The
Secretary shall issue regulations requiring foreign taxes to
be treated as expenses in determining pre-tax profit in
appropriate cases.
``(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) Determination of application of doctrine not
affected.--The determination of whether the economic
substance doctrine is relevant to a transaction shall be made
in the same manner as if this subsection had never been
enacted.
``(D) Transaction.--The term `transaction' includes a
series of transactions.''.
(b) Penalty for Underpayments Attributable to Transactions
Lacking Economic Substance.--
(1) In general.--Subsection (b) of section 6662 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 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.--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) 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.--
(1) Reasonable cause exception for underpayments.--
Subsection (c) of section 6664 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 transactions described in section 6662(b)(6).''.
(2) Reasonable cause exception for reportable transaction
understatements.--Subsection (d) of section 6664 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 transactions described in section
6662(b)(6).''.
(d) Application of Penalty for Erroneous Claim for Refund
or Credit to Noneconomic Substance Transactions.--Section
6676 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.
[[Page H2164]]
(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. 1410. TIME FOR PAYMENT OF CORPORATE ESTIMATED TAXES.
The percentage under paragraph (1) of section 202(b) of the
Corporate Estimated Tax Shift Act of 2009 in effect on the
date of the enactment of this Act is increased by 15.75
percentage points.
Subtitle F--Other Provisions
SEC. 1501. COMMUNITY COLLEGE AND CAREER TRAINING GRANT
PROGRAM.
Section 279(b) of the Trade Act of 1974 (19 U.S.C.
2372a(b)) is amended by striking ``Supplement'' and all that
follows through ``Funds'' and inserting ``There are'' and by
striking ``pursuant'' and all that follows and inserting
``$500,000,000 for each of fiscal years 2011, 2012, 2013, and
2014 to carry out this subchapter, except that the
limitations contained in section 278(a)(2) shall not apply to
such funds and each State shall receive not less than 0.5
percent of the amount appropriated pursuant to this
subsection for each such fiscal year.''.
TITLE II--EDUCATION AND HEALTH
Subtitle A--Education
SEC. 2001. SHORT TITLE; REFERENCES.
(a) Short Title.--This subtitle may be cited as the ``SAFRA
Act''.
(b) References.--Except as otherwise expressly provided,
whenever in this subtitle an amendment or repeal is expressed
in terms of an amendment to, or repeal of, a section or other
provision, the reference shall be considered to be made to a
section or other provision of the Higher Education Act of
1965 (20 U.S.C. 1001 et seq.).
PART I--INVESTING IN STUDENTS AND FAMILIES
SEC. 2101. FEDERAL PELL GRANTS.
(a) Amount of Grants.--Section 401(b) (20 U.S.C. 1070a(b))
is amended--
(1) by amending paragraph (2)(A) to read as follows:
``(A) The amount of the Federal Pell Grant for a student
eligible under this part shall be--
``(i) the maximum Federal Pell Grant, as specified in the
last enacted appropriation Act applicable to that award year,
plus
``(ii) the amount of the increase calculated under
paragraph (8)(B) for that year, less
``(iii) an amount equal to the amount determined to be the
expected family contribution with respect to that student for
that year.''; and
(2) in paragraph (8)--
(A) in subparagraph (A)--
(i) in the matter preceding clause (i), by striking ``, to
carry out subparagraph (B) of this paragraph''; and
(ii) by striking clauses (iii) through (x) and inserting
the following:
``(iii) to carry out subparagraph (B) of this paragraph,
such sums as may be necessary for fiscal year 2010 and each
subsequent fiscal year to provide the amount of increase of
the maximum Federal Pell Grant required by clauses (ii) and
(iii) of subparagraph (B); and
``(iv) to carry out this section, $13,500,000,000 for
fiscal year 2011.'';
(B) in subparagraph (B)--
(i) in the matter preceding clause (i), by striking
``subparagraph (A)'' and inserting ``clauses (i) through
(iii) of subparagraph (A)'';
(ii) in clause (ii), by striking ``and 2011-2012'' and
inserting ``, 2011 092012, and 2012-2013''; and
(iii) by striking clause (iii) and inserting the following:
``(iii) the amount determined under subparagraph (C) for
each succeeding award year.'';
(C) by striking subparagraph (C) and inserting the
following:
``(C) Adjustment amounts.--
``(i) Award year 2013-2014.--For award year 2013-2014, the
amount determined under this subparagraph for purposes of
subparagraph (B)(iii) shall be equal to--
``(I) $5,550 or the total maximum Federal Pell Grant for
the preceding award year (as determined under clause
(v)(II)), whichever is greater, increased by a percentage
equal to the annual adjustment percentage for award year
2013-2014; reduced by
``(II) $4,860 or the maximum Federal Pell Grant for which a
student was eligible for the preceding award year, as
specified in the last enacted appropriation Act applicable to
that year, whichever is greater; and
``(III) rounded to the nearest $5.
``(ii) Award years 2014-2015 through 2017-2018.--For each
of the award years 2014-2015 through 2017-2018, the amount
determined under this subparagraph for purposes of
subparagraph (B)(iii) shall be equal to--
``(I) the total maximum Federal Pell Grant for the
preceding award year (as determined under clause (v)(II)),
increased by a percentage equal to the annual adjustment
percentage for the award year for which the amount under this
subparagraph is being determined; reduced by
``(II) $4,860 or the maximum Federal Pell Grant for which a
student was eligible for the preceding award year, as
specified in the last enacted appropriation Act applicable to
that year, whichever is greater; and
``(III) rounded to the nearest $5.
``(iii) Subsequent award years.--For award year 2018-2019
and each subsequent award year, the amount determined under
this subparagraph for purposes of subparagraph (B)(iii) shall
be equal to the amount determined under clause (ii) for award
year 2017-2018.
``(iv) Limitation on decreases.--Notwithstanding clauses
(i), (ii), and (iii), if the amount determined under clause
(i), (ii), or (iii) for a particular award year is less than
the amount determined under this paragraph for the award year
preceding that particular award year, then the amount
determined under such clause for that particular award year
shall be the amount determined under this paragraph for the
preceding award year.
``(v) Definitions.--For purposes of this subparagraph--
``(I) the term `annual adjustment percentage' as applied to
an award year, is equal to the estimated percentage change in
the Consumer Price Index (as determined by the Secretary,
using the definition in section 478(f)) for the most recent
calendar year ending prior to the beginning of that award
year; and
``(II) the term `total maximum Federal Pell Grant' as
applied to a preceding award year, is equal to the sum of--
``(aa) the maximum Federal Pell Grant for which a student
is eligible during an award year, as specified in the last
enacted appropriation Act applicable to that preceding award
year; and
``(bb) the amount of the increase in the maximum Federal
Pell Grant required by this paragraph for that preceding
award year.'';
(D) by striking subparagraph (E); and
(E) by redesignating subparagraph (F) as subparagraph (E).
(b) Conforming Amendments.--Title IV (20 U.S.C. 1070 et
seq.) is further amended--
(1) in section 401(b) (20 U.S.C. 1070a(b))--
(A) in paragraph (4)--
(i) by striking ``maximum basic grant level specified in
the appropriate appropriation Act'' and inserting ``maximum
amount of a Federal Pell Grant award determined under
paragraph (2)(A)''; and
(ii) by striking ``such level'' each place it appears and
inserting ``such Federal Pell Grant amount'' in each such
place; and
(B) in paragraph (6), by striking ``the grant level
specified in the appropriate Appropriation Act for this
subpart for such year'' and inserting ``the maximum amount of
a Federal Pell Grant award determined under paragraph (2)(A),
for which a student is eligible during such award year'';
(2) in section 402D(d)(1) (20 U.S.C. 1070a-14(d)(1)), by
striking ``exceed the maximum'' and all that follows through
``Grant, for'' and inserting ``exceed the Federal Pell Grant
amount, determined under section 401(b)(2)(A), for which a
student is eligible, or be less than the minimum Federal Pell
Grant amount described in section 401(b)(4), for'';
(3) in section 435(a)(5)(A)(i)(I) (20 U.S.C.
1085(a)(5)(A)(i)(I)), by striking ``one-half the maximum
Federal Pell Grant award for which a student would be
eligible'' and inserting ``one-half the Federal Pell Grant
amount, determined under section 401(b)(2)(A), for which a
student would be eligible'';
(4) in section 483(e)(3)(A)(ii) (20 U.S.C.
1090(e)(3)(A)(ii)), by striking ``based on the maximum
Federal Pell Grant award at the time of application'' and
inserting ``based on the Federal Pell Grant amount,
determined under section 401(b)(2)(A), for which a student is
eligible at the time of application'';
(5) in section 485E(b)(1)(A) (20 U.S.C. 1092f(b)(1)(A)), by
striking ``of such students' potential eligibility for a
maximum Federal Pell Grant under subpart 1 of part A'' and
inserting ``of such students' potential eligibility for the
Federal Pell Grant amount, determined under section
401(b)(2)(A), for which the student would be eligible''; and
(6) in section 894(f)(2)(C)(ii)(I) (20 U.S.C.
1161y(f)(2)(C)(ii)(I)), by striking ``the maximum Federal
Pell Grant for each award year'' and inserting ``the Federal
Pell Grant amount, determined under section 401(b)(2)(A), for
which a student may be eligible for each award year''.
(c) Effective Date.--The amendments made by subsections (a)
and (b) shall take effect on July 1, 2010.
SEC. 2102. COLLEGE ACCESS CHALLENGE GRANT PROGRAM.
Section 781 (20 U.S.C. 1141) is amended--
(1) in the first sentence of subsection (a), by striking
``$66,000,000'' and all that follows through the period and
inserting ``$150,000,000 for each of the fiscal years 2010
through 2014. The authority to award grants under this
section shall expire at the end of fiscal year 2014.''; and
(2) in subsection (c)(2), by striking ``0.5 percent'' and
inserting ``1.0 percent''.
SEC. 2103. INVESTMENT IN HISTORICALLY BLACK COLLEGES AND
UNIVERSITIES AND MINORITY-SERVING INSTITUTIONS.
Section 371(b)(1)(A) (20 U.S.C. 1067q(b)(1)(A)) is amended
by striking ``and 2009.'' and all that follows and inserting
``through 2019. The authority to award grants under this
section shall expire at the end of fiscal year 2019.''.
PART II--STUDENT LOAN REFORM
SEC. 2201. TERMINATION OF FEDERAL FAMILY EDUCATION LOAN
APPROPRIATIONS.
Section 421 (20 U.S.C. 1071) is amended--
(1) in subsection (b), in the first sentence of the matter
following paragraph (6), by inserting ``, except that no sums
may be expended after June 30, 2010, with respect to loans
under this part for which the first disbursement is after
such date'' after ``expended''; and
(2) by adding at the end the following new subsection:
``(d) Termination of Authority To Make or Insure New
Loans.--Notwithstanding paragraphs (1) through (6) of
subsection (b) or any other provision of law--
``(1) no new loans (including consolidation loans) may be
made or insured under this part after June 30, 2010; and
``(2) no funds are authorized to be appropriated, or may be
expended, under this Act or any other Act to make or insure
loans under this part (including consolidation loans) for
which the first disbursement is after June 30, 2010,
[[Page H2165]]
except as expressly authorized by an Act of Congress enacted
after the date of enactment of the SAFRA Act.''.
SEC. 2202. TERMINATION OF FEDERAL LOAN INSURANCE PROGRAM.
Section 424(a) (20 U.S.C. 1074(a)) is amended by striking
``September 30, 1976,'' and all that follows and inserting
``September 30, 1976, for each of the succeeding fiscal years
ending prior to October 1, 2009, and for the period from
October 1, 2009, to June 30, 2010, for loans first disbursed
on or before June 30, 2010.''.
SEC. 2203. TERMINATION OF APPLICABLE INTEREST RATES.
Section 427A(l) (20 U.S.C. 1077a(l)) is amended--
(1) in the subsection heading, by inserting ``and Before
July 1, 2010'' after ``2006'';
(2) in paragraph (1), by inserting ``and before July 1,
2010,'' after ``July 1, 2006,'';
(3) in paragraph (2), by inserting ``and before July 1,
2010,'' after ``July 1, 2006,'';
(4) in paragraph (3), by inserting ``and that was disbursed
before July 1, 2010,'' after ``July 1, 2006,''; and
(5) in paragraph (4)--
(A) in the matter preceding subparagraph (A), by striking
``July 1, 2012'' and inserting ``July 1, 2010''; and
(B) by repealing subparagraphs (D) and (E).
SEC. 2204. TERMINATION OF FEDERAL PAYMENTS TO REDUCE STUDENT
INTEREST COSTS.
(a) Higher Education Act of 1965.--Section 428 (20 U.S.C.
1078) is amended--
(1) in subsection (a)--
(A) in paragraph (1), in the matter preceding subparagraph
(A), by inserting ``for which the first disbursement is made
before July 1, 2010, and'' after ``eligible institution'';
and
(B) in paragraph (5), by striking ``September 30, 2014,''
and all that follows through the period and inserting ``June
30, 2010.'';
(2) in subsection (b)(1)--
(A) in subparagraph (G)(ii), by inserting ``and before July
1, 2010,'' after ``July 1, 2006,''; and
(B) in subparagraph (H)(ii), by inserting ``and that are
first disbursed before July 1, 2010,'' after ``July 1,
2006,'';
(3) in subsection (f)(1)(A)(ii)--
(A) by striking ``during fiscal years beginning''; and
(B) by inserting ``and first disbursed before July 1,
2010,'' after ``October 1, 2003,''; and
(4) in subsection (j)(1), by inserting ``, before July 1,
2010,'' after ``section 435(d)(1)(D) of this Act shall''.
(b) College Cost Reduction and Access Act.--Section 303 of
the College Cost Reduction and Access Act (Public Law 110-84)
is repealed.
SEC. 2205. TERMINATION OF FFEL PLUS LOANS.
Section 428B(a)(1) (20 U.S.C. 1078-2(a)(1)) is amended by
striking ``A graduate'' and inserting ``Prior to July 1,
2010, a graduate''.
SEC. 2206. FEDERAL CONSOLIDATION LOANS.
(a) In General.--Section 428C (20 U.S.C. 1078-3) is
amended--
(1) in subsection (a)(4)(A), by inserting ``, and first
disbursed before July 1, 2010'' after ``under this part'';
(2) in subsection (b)--
(A) in paragraph (1)(E), by inserting before the semicolon
``, and before July 1, 2010''; and
(B) in paragraph (5), by striking ``In the event that'' and
inserting ``If, before July 1, 2010,'';
(3) in subsection (c)(1)--
(A) in subparagraph (A)(ii), by inserting ``and that is
disbursed before July 1, 2010,'' after ``2006,''; and
(B) in subparagraph (C), by inserting ``and disbursed
before July 1, 2010,'' after ``1994,''; and
(4) in subsection (e), by striking ``September 30, 2014.''
and inserting ``June 30, 2010. No loan may be made under this
section for which the disbursement is on or after July 1,
2010.''.
(b) Temporary Loan Consolidation Authority.--Part D of
title IV (20 U.S.C. 1087a et seq.) is amended by inserting
after section 459A (20 U.S.C. 1087i) the following:
``SEC. 459B. TEMPORARY LOAN CONSOLIDATION AUTHORITY.
``(a) Temporary Loan Consolidation Authority.--
``(1) In general.--A borrower who has 1 or more loans in 2
or more of the categories described in paragraph (2), and who
has not yet entered repayment on 1 or more of those loans in
any of the categories, may consolidate all of the loans of
the borrower that are described in paragraph (2) into a
Federal Direct Consolidation Loan during the period described
in paragraph (3).
``(2) Categories of loans that may be consolidated.--The
categories of loans that may be consolidated under paragraph
(1) are--
``(A) loans made under this part;
``(B) loans purchased by the Secretary pursuant to section
459A; and
``(C) loans made under part B that are held by an eligible
lender, as such term is defined in section 435(d).
``(3) Time period in which loans may be consolidated.--The
Secretary may make a Federal Direct Consolidation Loan under
this section to a borrower whose application for such Federal
Direct Consolidation Loan is received on or after July 1,
2010, and before July 1, 2011.
``(b) Terms of Loans.--A Federal Direct Consolidation Loan
made under this section shall have the same terms and
conditions as a Federal Direct Consolidation Loan made under
section 455(g), except that--
``(1) in determining the applicable rate of interest on the
Federal Direct Consolidation Loan made under this section
(other than on a Federal Direct Consolidation Loan described
in paragraph (2)), section 427A(l)(3) shall be applied
without rounding the weighted average of the interest rate on
the loans consolidated to the nearest higher one-eighth of 1
percent as described in subparagraph (A) of section
427A(l)(3); and
``(2) if a Federal Direct Consolidation Loan made under
this section that repays a loan which is subject to an
interest rate determined under section 427A(g)(2), (j)(2), or
(k)(2), then the interest rate for such Federal Direct
Consolidation Loan shall be calculated--
``(A) by using the applicable rate of interest described in
section 427A(g)(2), (j)(2), or (k)(2), respectively; and
``(B) in accordance with section 427A(l)(3).''.
SEC. 2207. TERMINATION OF UNSUBSIDIZED STAFFORD LOANS FOR
MIDDLE-INCOME BORROWERS.
Section 428H (20 U.S.C. 1078-8) is amended--
(1) in subsection (a), by inserting ``that are first
disbursed before July 1, 2010,'' after ``under this part'';
(2) in subsection (b)--
(A) by striking ``Any student'' and inserting ``Prior to
July 1, 2010, any student''; and
(B) by inserting ``for which the first disbursement is made
before such date'' after ``unsubsidized Federal Stafford
Loan''; and
(3) in subsection (h), by inserting ``and that are first
disbursed before July 1, 2010,'' after ``July 1, 2006,''.
SEC. 2208. TERMINATION OF SPECIAL ALLOWANCES.
Section 438 (20 U.S.C. 1087-1) is amended--
(1) in subsection (b)(2)(I)--
(A) in the subclause heading, by inserting ``, and before
july 1, 2010'' after ``2000'';
(B) in clause (i), by inserting ``and before July 1,
2010,'' after ``2000,'';
(C) in clause (ii)(II), by inserting ``and before July 1,
2010,'' after ``2006,'';
(D) in clause (iii), by inserting ``and before July 1,
2010,'' after ``2000,'';
(E) in clause (iv), by inserting ``and that is disbursed
before July 1, 2010,'' after ``2000,'';
(F) in clause (v)(I), by inserting ``and before July 1,
2010,'' after ``2006,''; and
(G) in clause (vi)--
(i) in the clause heading, by inserting ``, and before july
1, 2010'' after ``2007''; and
(ii) in the matter preceding subclause (I), by inserting
``and before July 1, 2010,'' after ``2007,'';
(2) in subsection (c)--
(A) in paragraph (2)(B)--
(i) in clause (iii), by inserting ``and'' after the
semicolon;
(ii) in clause (iv), by striking ``; and'' and inserting a
period; and
(iii) by striking clause (v); and
(B) in paragraph (6), by inserting ``and first disbursed
before July 1, 2010,'' after ``1992,''; and
(3) in subsection (d)(2)(B), by inserting ``, and before
July 1, 2010'' after ``2007''.
SEC. 2209. ORIGINATION OF DIRECT LOANS AT INSTITUTIONS
OUTSIDE THE UNITED STATES.
(a) Loans for Students Attending Institutions Outside the
United States.--Section 452 (20 U.S.C. 1087b) is amended by
adding at the end the following:
``(d) Institutions Outside the United States.--Loan funds
for students (and parents of students) attending institutions
outside the United States shall be disbursed through a
financial institution located or operating in the United
States and designated by the Secretary to serve as the agent
of such institutions with respect to the receipt of the
disbursements of such loan funds and the transfer of such
funds to such institutions. To be eligible to receive funds
under this part, an institution outside the United States
shall make arrangements with the agent designated by the
Secretary under this subsection to receive funds under this
part.''.
(b) Conforming Amendments.--
(1) Amendments.--Section 102 (20 U.S.C. 1002), as amended
by section 102 of the Higher Education Opportunity Act
(Public Law 110-315) and section 101 of Public Law 111-39, is
amended--
(A) by striking ``part B'' each place the term appears and
inserting ``part D'';
(B) in subsection (a)(1)(C), by inserting ``, consistent
with the requirements of section 452(d)'' before the period
at the end; and
(C) in subsection (a)(2)(A)--
(i) in the second sentence of the matter preceding clause
(i), by striking ``made, insured, or guaranteed'' and
inserting ``made''; and
(ii) in clause (iii)--
(I) in subclause (III), by striking ``only Federal
Stafford'' and all that follows through ``section 428B'' and
inserting ``only Federal Direct Stafford Loans under section
455(a)(2)(A), Federal Direct Unsubsidized Stafford Loans
under section 455(a)(2)(D), or Federal Direct PLUS Loans
under section 455(a)(2)(B)''; and
(II) in subclause (V), by striking ``a Federal Stafford''
and all that follows through ``section 428B'' and inserting
``a Federal Direct Stafford Loan under section 455(a)(2)(A),
a Federal Direct Unsubsidized Stafford Loan under section
455(a)(2)(D), or a Federal Direct PLUS Loan under section
455(a)(2)(B)''.
(2) Effective date.--The amendments made by subparagraph
(C) of paragraph (1) shall be effective on July 1, 2010, as
if enacted as part of section 102(a)(1) of the Higher
Education Opportunity Act (Public Law 110-315) and subject to
section 102(e) of such Act as amended by section 101(a)(2) of
Public Law 111-39 (20 U.S.C. 1002 note).
SEC. 2210. CONFORMING AMENDMENTS.
(a) Amendments.--Section 454 (20 U.S.C. 1087d) is amended--
(1) in subsection (a)--
(A) by striking paragraph (4); and
(B) by redesignating paragraphs (5) through (7) as
paragraphs (4) through (6), respectively; and
(2) in subsection (b)(2), by striking ``(5), (6), and (7)''
and inserting ``(5), and (6)''.
[[Page H2166]]
(b) Effective Date.--The amendments made by subsection (a)
shall take effect on July 1, 2010.
SEC. 2211. TERMS AND CONDITIONS OF LOANS.
(a) In General.--Section 455 (20 U.S.C. 1087e) is amended--
(1) in subsection (a)(1), by inserting ``, and first
disbursed on June 30, 2010,'' before ``under sections 428'';
and
(2) in subsection (g)--
(A) by inserting ``, including any loan made under part B
and first disbursed before July 1, 2010'' after ``section
428C(a)(4)''; and
(B) by striking the third sentence.
(b) Effective Date.--The amendment made by subsection
(a)(1) shall apply with respect to loans first disbursed
under part D of title IV of the Higher Education Act of 1965
(20 U.S.C. 1087a et seq.) on or after July 1, 2010.
SEC. 2212. CONTRACTS; MANDATORY FUNDS.
(a) Contracts.--Section 456 (20 U.S.C. 1087f) is amended--
(1) in subsection (a)--
(A) by inserting after paragraph (3) the following new
paragraph:
``(4) Servicing by eligible not-for-profit servicers.--
``(A) Servicing contracts.--
``(i) In general.--The Secretary shall contract with each
eligible not-for-profit servicer to service loans originated
under this part, if the servicer--
``(I) meets the standards for servicing Federal assets that
apply to contracts awarded pursuant to paragraph (1); and
``(II) has the capacity to service the applicable loan
volume allocation described in subparagraph (B).
``(ii) Competitive market rate determination for first
100,000 borrower accounts.--The Secretary shall establish a
separate pricing tier for each of the first 100,000 borrower
loan accounts at a competitive market rate.
``(iii) Ineligibility.--An eligible not-for-profit servicer
shall no longer be eligible for a contract under this
paragraph after July 1, 2014, if--
``(I) the servicer has not been awarded such a contract
before that date; or
``(II) the servicer's contract was terminated, and the
servicer had not reapplied for, and been awarded, a contract
under this paragraph.
``(B) Allocations.--
``(i) In general.--The Secretary shall (except as provided
in clause (ii)) allocate to an eligible not-for-profit
servicer, subject to the contract of such servicer described
in subparagraph (A), the servicing rights for the loan
accounts of 100,000 borrowers (including borrowers who
borrowed loans in a prior year that were serviced by the
servicer).
``(ii) Servicer allocation.--The Secretary may reallocate,
increase, reduce, or terminate an eligible not-for-profit
servicer's allocation of servicing rights under clause (i)
based on the performance of such servicer, on the same terms
as loan allocations provided by contracts awarded pursuant to
paragraph (1).''; and
(2) by adding at the end the following:
``(c) Definition of Eligible Not-for-Profit Servicer.--In
this section:
``(1) In general.--The term `eligible not-for-profit
servicer' means an entity--
``(A) that is not owned or controlled in whole or in part
by--
``(i) a for profit entity; or
``(ii) a nonprofit entity having its principal place of
business in another State; and
``(B) that--
``(i) as of July 1, 2009--
``(I) meets the definition of an eligible not-for-profit
holder under section 435(p), except that such term does not
include eligible lenders described in paragraph (1)(D) of
such section; and
``(II) was performing, or had entered into a contract with
a third party servicer (as such term is defined in section
481(c)) who was performing, student loan servicing functions
for loans made under part B of this title;
``(ii) notwithstanding clause (i), as of July 1, 2009--
``(I) is the sole beneficial owner of a loan for which the
special allowance rate is calculated under section
438(b)(2)(I)(vi)(II) because the loan is held by an eligible
lender trustee that is an eligible not-for-profit holder as
defined under section 435(p)(1)(D); and
``(II) was performing, or had entered into a contract with
a third party servicer (as such term is defined in section
481(c)) who was performing, student loan servicing functions
for loans made under part B of this title; or
``(iii) is an affiliated entity of an eligible not-for-
profit servicer described in clause (i) or (ii) that--
``(I) directly employs, or will directly employ (on or
before the date the entity begins servicing loans under a
contract awarded by the Secretary pursuant to subsection
(a)(3)(A)), the majority of individuals who perform borrower-
specific student loan servicing functions; and
``(II) as of July 1, 2009, was performing, or had entered
into a contract with a third party servicer (as such term is
defined in section 481(c)) who was performing, student loan
servicing functions for loans made under part B of this
title.
``(2) Affiliated entity.--For the purposes of paragraph
(1), the term `affiliated entity'--
``(A) means an entity contracted to perform services for an
eligible not-for-profit servicer that--
``(i) is a nonprofit entity or is wholly owned by a
nonprofit entity; and
``(ii) is not owned or controlled, in whole or in part,
by--
``(I) a for-profit entity; or
``(II) an entity having its principal place of business in
another State; and
``(B) may include an affiliated entity that is established
by an eligible not-for-profit servicer after the date of
enactment of the SAFRA Act, if such affiliated entity is
otherwise described in paragraph (1)(B)(iii)(I) and
subparagraph (A) of this paragraph.''.
(b) Mandatory Funds.--
(1) Amendments.--Section 458(a) (20 U.S.C. 1087h(a)) is
amended--
(A) by redesignating paragraph (5) as paragraph (8);
(B) by redesignating paragraphs (2) through (4) as
paragraphs (3) through (5), respectively;
(C) by inserting after paragraph (1) the following new
paragraph:
``(2) Mandatory funds for eligible not-for-profit-
servicers.--For fiscal years 2010 through 2019, there shall
be available to the Secretary, in addition to any other
amounts appropriated to carry out this paragraph and out of
any money in the Treasury not otherwise appropriated, funds
to be obligated for administrative costs of servicing
contracts with eligible not-for-profit servicers as described
in section 456.''; and
(D) by inserting after paragraph (5), as redesignated by
subparagraph (B) of this paragraph, the following:
``(6) Technical assistance to institutions of higher
education.--
``(A) Provision of assistance.--The Secretary shall provide
institutions of higher education participating, or seeking to
participate, in the loan programs under this part with
technical assistance in establishing and administering such
programs.
``(B) Funds.--There are authorized to be appropriated, and
there are appropriated, to carry out this paragraph (in
addition to any other amounts appropriated to carry out this
paragraph and out of any money in the Treasury not otherwise
appropriated), $50,000,000 for fiscal year 2010.
``(C) Definition.--In this paragraph, the term `assistance'
means the provision of technical support, training,
materials, technical assistance, and financial assistance.
``(7) Additional payments.--
``(A) Provision of assistance.--The Secretary shall provide
payments to loan servicers for retaining jobs at locations in
the United States where such servicers were operating under
part B on January 1, 2010.
``(B) Funds.--There are authorized to be appropriated, and
there are appropriated, to carry out this paragraph (in
addition to any other amounts appropriated to carry out this
paragraph and out of any money in the Treasury not otherwise
appropriated), $25,000,000 for each of the fiscal years 2010
and 2011.''.
(2) Conforming amendment.--Section 458 (20 U.S.C. 1087h) is
further amended by striking ``subsection (a)(3)'' in
subsection (b) and inserting ``subsection (a)(4)''.
SEC. 2213. INCOME-BASED REPAYMENT.
Section 493C (20 U.S.C. 1098e) is amended by adding at the
end the following new subsection:
``(e) Special Terms for New Borrowers on and After July 1,
2014.--With respect to any loan made to a new borrower on or
after July 1, 2014--
``(1) subsection (a)(3)(B) shall be applied by substituting
`10 percent' for `15 percent'; and
``(2) subsection (b)(7)(B) shall be applied by substituting
`20 years' for `25 years'.''.
Subtitle B--Health
SEC. 2301. INSURANCE REFORMS.
(a) Extending Certain Insurance Reforms to Grandfathered
Plans.--Section 1251(a) of the Patient Protection and
Affordable Care Act, as added by section 10103(d) of such
Act, is amended by adding at the end the following:
``(4) Application of certain provisions.--
``(A) In general.--The following provisions of the Public
Health Service Act (as added by this title) shall apply to
grandfathered health plans for plan years beginning with the
first plan year to which such provisions would otherwise
apply:
``(i) Section 2708 (relating to excessive waiting periods).
``(ii) Those provisions of section 2711 relating to
lifetime limits.
``(iii) Section 2712 (relating to rescissions).
``(iv) Section 2714 (relating to extension of dependent
coverage).
``(B) Provisions applicable only to group health plans.--
``(i) Provisions described.--Those provisions of section
2711 relating to annual limits and the provisions of section
2704 (relating to pre-existing condition exclusions) of the
Public Health Service Act (as added by this subtitle) shall
apply to grandfathered health plans that are group health
plans for plan years beginning with the first plan year to
which such provisions otherwise apply.
``(ii) Adult child coverage.--For plan years beginning
before January 1, 2014, the provisions of section 2714 of the
Public Health Service Act (as added by this subtitle) shall
apply in the case of an adult child with respect to a
grandfathered health plan that is a group health plan only if
such adult child is not eligible to enroll in an eligible
employer-sponsored health plan (as defined in section
5000A(f)(2) of the Internal Revenue Code of 1986) other than
such grandfathered health plan.''.
(b) Clarification Regarding Dependent Coverage.--Section
2714(a) of the Public Health Service Act, as added by section
1001(5) of the Patient Protection and Affordable Care Act,
is amended by striking ``(who is not married)''.
SEC. 2302. DRUGS PURCHASED BY COVERED ENTITIES.
Section 340B of the Public Health Service Act (42 U.S.C.
256b), as amended by sections 7101 and 7102 of the Patient
Protection and Affordable Care Act, is amended--
(1) in subsection (a)--
(A) in paragraphs (1), (2), (5), (7), and (9), by striking
the terms ``covered drug'' and ``covered drugs'' each place
either term appears and inserting ``covered outpatient drug''
or ``covered outpatient drugs'', respectively;
(B) in paragraph (4)(L)--
(i) in clause (i), by striking ``and'' at the end;
[[Page H2167]]
(ii) in clause (ii), by striking the period and inserting
``; and''; and
(iii) by inserting after clause (ii), the following:
``(iii) does not obtain covered outpatient drugs through a
group purchasing organization or other group purchasing
arrangement.''; and
(C) in paragraph (5)--
(i) by striking subparagraph (C);
(ii) by redesignating subparagraphs (D) and (E) as
subparagraphs (C) and (D), respectively; and
(iii) in subparagraph (D), as so redesignated, by striking
``subparagraph (D)'' and inserting ``subparagraph (C)'';
(2) by striking subsection (c);
(3) in subsection (d)--
(A) by striking ``covered drugs'' each place it appears and
inserting ``covered outpatient drugs'';
(B) by striking ``(a)(5)(D)'' each place it appears and
inserting ``(a)(5)(C)''; and
(C) by striking ``(a)(5)(E)'' each place it appears and
inserting ``(a)(5)(D)''; and
(4) by inserting after subsection (d) the following:
``(e) Exclusion of Orphan Drugs for Certain Covered
Entities.--For covered entities described in subparagraph
(M), (N), or (O) of subsection (a)(4), the term `covered
outpatient drug' shall not include a drug designated by the
Secretary under section 526 of the Federal Food, Drug, and
Cosmetic Act for a rare disease or condition.''.
SEC. 2303. COMMUNITY HEALTH CENTERS.
Section 10503(b)(1) of the Patient Protection and
Affordable Care Act is amended--
(1) in subparagraph (A), by striking ``700,000,000'' and
inserting ``1,000,000,000'';
(2) in subparagraph (B), by striking ``800,000,000'' and
inserting ``1,200,000,000'';
(3) in subparagraph (C), by striking ``1,000,000,000'' and
inserting ``1,500,000,000'';
(4) in subparagraph (D), by striking ``1,600,000,000'' and
inserting ``2,200,000,000''; and
(5) in subparagraph (E), by striking ``2,900,000,000'' and
inserting ``3,600,000,000''.
The SPEAKER pro tempore. Pursuant to House Resolution 1203, the
previous question is ordered on the bill, as amended.
The question is on the engrossment and third reading of the bill.
The bill was ordered to be engrossed and read a third time, and was
read the third time.
Motion to Recommit
Mr. CAMP. Mr. Speaker, I have a motion to recommit at the desk.
The SPEAKER pro tempore. Is the gentleman opposed to the bill?
Mr. CAMP. In its current form.
The SPEAKER pro tempore. The Clerk will designate the motion.
The text of the motion is as follows:
Motion to recommit offered by Mr. Camp:
Mr. Camp moves to recommit the bill H.R. 4872 to the
Committee on the Budget with instructions to report the same
back to the House forthwith with the following amendments:
Add at the end of section 1002 (relating to individual
responsibility) the following:
(c) Application of Penalty.--Section 5000A(g)(1) of the
Internal Revenue Code of 1986, as added by section 1501(b) of
the Patient Protection and Affordable Care Act and amended by
section 10106 of such Act, is amended to read as follows:
``(1) In general.--The penalty provided by this section
shall be paid upon notice and demand by the Secretary, and
except as provided in paragraph (2), shall be assessed and
collected in the same manner as an assessable penalty under
subchapter B of chapter 68. The penalties provided by this
section shall, subject to appropriations, be deposited by the
Secretary in the the Trust Funds established under title II
of the Social Security Act (in such proportions as the
Secretary shall specify). The value of such Trust Funds shall
be calculated each year as if the amounts described in the
previous sentence had been appropriated and deposited into
such Trust Funds.''.
At the end of subtitle A of title I, add the following:
SEC. 1006. SPECIAL RULES RELATING TO COVERAGE OF ABORTION
SERVICES.
(a) In General.--Section 1303 of the Patient Protection and
Affordable Care Act, as amended by section 10104(c) of such
Act, is amended--
(1) in the section heading, by inserting ``RELATING TO
COVERAGE OF ABORTION SERVICES'' after ``SPECIAL RULES''; and
(2) by striking subsection (a) and all of subsection (b)
that precedes paragraph (4) and inserting the following:
``(a) In General.--Nothing in this Act (or any amendment
made by this Act) shall be construed to require any health
plan to provide coverage of abortion services or to allow the
Secretary or any other person or entity implementing this Act
(or amendment) to require coverage of such services.
``(b) Limitation on Abortion Funding.--
``(1) In general.--None of the funds authorized or
appropriated by this Act (or an amendment made by this Act),
including credits under section 36B of the Internal Revenue
Code of 1986, shall be expended 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.
``(2) Option to purchase separate coverage or plan.--
Subject to paragraph (1), nothing in this subsection shall be
construed as prohibiting any non-Federal entity (including an
individual or a State or local government) from purchasing
separate coverage for abortions for which funding is
prohibited under this subsection, or a plan that includes
such abortions, so long as such coverage or plan is not
purchased using the non-Federal funds required to receive a
Federal payment, including a premium payment required for a
qualified health plan towards which the credit described in
paragraph (1) is applied or a State's or locality's
contribution of Medicaid matching funds.
``(3) Option to offer coverage or plan.--Subject to
paragraph (1), nothing in this subsection shall restrict any
non-Federal health insurance issuer offering a qualified
health plan from offering separate coverage for abortions for
which funding is prohibited under this subsection, or a plan
that includes such abortions, so long as any such issuer that
offers a qualified health plan through an Exchange that
includes coverage for abortions for which funding is
prohibited under this subsection also offers a qualified
health plan through the Exchange that is identical in every
respect except that it does not cover such abortions.''.
(b) Conforming Amendment for Multi-State Plans.--Section
1334(a) of the Patient Protection and Affordable Care Act, as
added by section 10104(q) of such Act, is amended by striking
paragraph (6) and redesignating paragraph (7) as paragraph
(6).
The SPEAKER pro tempore. Pursuant to the rule, the gentleman from
Michigan is recognized for 5 minutes in support of his motion.
Mr. HOYER. Mr. Speaker, is the motion going to be read?
The SPEAKER pro tempore. The rule dispenses with the reading. The
motion is merely designated.
The gentleman from Michigan is recognized for 5 minutes.
Mr. CAMP. As the previous vote shows, there is bipartisan opposition
to the health care bill the Senate sent to this House. It is with good
reason. The American people, Republicans and a few brave Democrats--34,
to be exact--34 brave Democrats have rejected it precisely because of
the legislation's deep flaws. The motion to recommit offers us a chance
to fix the most egregious defect, allowing taxpayer funds to subsidize
abortions.
Mr. Speaker, the very strict rules of the House waive the reading of
all of these rules and motions, but this motion ensures the Hyde
language remains the law of the land. The latest in a long string of
deals--the one made today with the President--does not protect the life
of unborn children. As the gentleman from Mississippi, a Democrat,
warned earlier today, anything the President does by Executive order,
he can undo by Executive order.
There is no bargaining or dealmaking when it comes to the life of the
unborn. A life is a life. And it is the responsibility of this House to
defend these children.
When this measure was last before the House, it passed
overwhelmingly, 240-194. It should do so again.
I now yield to the gentleman from Pennsylvania (Mr. Pitts) to further
discuss this motion to recommit.
Mr. PITTS. I rise in support of the motion before us. Over and over
again, polls have shown the public does not support Federal funding of
abortions. Unfortunately, the Senate rejected the will of the people
and passed a bill that has become known as the most massively pro-
abortion piece of legislation to come before Congress since Roe v.
Wade.
Despite the political runaround that we've been given this last week,
the facts remain before us today: The Senate bill departs from
longstanding current policy and achieves the exact opposite effect of
current law, and an Executive order promised by the President will not
change these facts. An Executive order does not trump a statute. The
courts will undoubtedly look to the legislative text to interpret the
law.
Moreover, the promised order fails to even correct the egregious pro-
life concerns contained in this bill. It will simply reiterate the
meaningless accounting scheme cooked up by the Senate bill. Regardless
of what type of gimmick is employed to facilitate the abortion
payments, the result will be the same. The abortion rate will rise and
more unborn lives will be lost.
[[Page H2168]]
The Executive order does nothing to prevent funding for abortion in
the co-op program or prevent funding for abortion in the high-risk
insurance pool program. The Executive order does not prevent HRSA from
issuing regs that include abortion as a preventive service, thereby
mandating all individual plans and group plans include abortion as a
required service. The Executive order does nothing to prevent that
abortion surcharge mandate from being implemented. It is full of
loopholes.
Mr. Speaker, I urge my colleagues to reinstate the pro-life
protections that passed this Chamber last November in a bipartisan
vote, the Stupak-Pitts amendment. I urge my colleagues to vote ``yes''
on this motion.
Mr. CAMP. Mr. Speaker, I now yield to the gentleman from New Jersey
(Mr. Smith).
Mr. SMITH of New Jersey. Mr. Speaker, in a dramatic reversal of
current law, ObamaCare, as just passed, authorizes health insurance
policies funded with tax credits and cost reduction payments to pay for
abortion on demand and forces the issuers of federally subsidized plans
to collect a new abortion fee and abortion surtax from every enrollee
to pay for other people's abortions. Insurance companies need only
segregate the funds--a mere bookkeeping exercise--to subsidize
unrestricted, publicly funded abortions.
OPM will also administer multi-State insurance plans with abortion,
another radical departure from the status quo. What of the Executive
order? With all due respect, what a joke. It does absolutely nothing to
mitigate or change in any way the huge expansion of public funding of
abortion.
For example--and I ask Members to read it--section 2 only directs
officials, pursuant to provisions of the bill just passed, to establish
a model set of segregation guidelines. So, in other words, the abortion
expansion is unabated.
I ask Members to support Stupak-Pitts and the motion to recommit.
Mr. HOYER. Mr. Speaker, I rise in opposition to the motion.
The SPEAKER pro tempore. The gentleman from Maryland is recognized
for 5 minutes.
Mr. HOYER. I thank the Speaker.
Ladies and gentlemen, we have come a far pace. The majority of this
House has just voted to do for Americans what a hundred years of
Presidents have asked for. We are on the cusp of a great victory for
America and for Americans. This motion is inconsistent with
reconciliation, a process that 72 percent of the time was pursued by
the other party. They know that this motion is not in order and they
know this motion would not have support in the Senate, so they are
indirectly trying to kill this bill. However, as well, I think they
well misstate the case.
I yield to the gentleman from Michigan.
{time} 2300
Mr. STUPAK. I thank the gentleman for yielding.
The motion to recommit purports to be a right-to-life motion, in the
spirit of the Stupak amendment. But as the author of the Stupak
amendment, this motion is nothing more than an opportunity to continue
to deny 32 million Americans health care. The motion is really a last-
ditch effort of 98 years of denying Americans health care.
The motion to recommit does not promote life. It is the Democrats who
have stood up for the principle of no public funding for abortions. It
is Democrats, through the President's executive order, that ensures the
sanctity of life is protected, because all life is precious and all
life should be honored. Democrats guarantee all life from the unborn to
the last breath of a senior citizen is honored and respected. For the
unborn child, his or her mother will finally have pre-and postnatal
care under our bill. If the child is born with mental problems, we
provide medical care without bankrupting the family.
For the Republicans to now claim that we send the bill back to
committee under the guise of protecting life is disingenuous. This
motion is really to politicize life, not prioritize life. We stand for
the American people. We stand up for life. Vote ``no'' on this motion
to recommit.
Mr. HOYER. My colleagues, we have come this far not to be thwarted by
a procedural motion that will never have effect. They know that. We
know that. Vote ``no.'' Vote ``yes'' for the health care of all
America.
I yield back the balance of my time.
The SPEAKER pro tempore. Without objection, the previous question is
ordered on the motion to recommit.
There was no objection.
The SPEAKER pro tempore. The question is on the motion to recommit.
The question was taken; and the Speaker pro tempore announced that
the noes appeared to have it.
Recorded Vote
Mr. CAMP. Mr. Speaker, I demand a recorded vote.
A recorded vote was ordered.
The vote was taken by electronic device, and there were--ayes 199,
noes 232, not voting 0, as follows:
[Roll No. 166]
AYES--199
Aderholt
Akin
Alexander
Altmire
Austria
Bachmann
Bachus
Barrett (SC)
Barrow
Bartlett
Barton (TX)
Berry
Biggert
Bilbray
Bilirakis
Bishop (UT)
Blackburn
Blunt
Boehner
Bonner
Bono Mack
Boozman
Boren
Boustany
Brady (TX)
Bright
Broun (GA)
Brown (SC)
Brown-Waite, Ginny
Buchanan
Burgess
Burton (IN)
Buyer
Calvert
Camp
Campbell
Cantor
Cao
Capito
Carter
Cassidy
Castle
Chaffetz
Chandler
Childers
Coble
Coffman (CO)
Cole
Conaway
Costello
Crenshaw
Culberson
Davis (KY)
Davis (TN)
Deal (GA)
Dent
Diaz-Balart, L.
Diaz-Balart, M.
Donnelly (IN)
Dreier
Duncan
Ehlers
Emerson
Fallin
Flake
Fleming
Forbes
Fortenberry
Foxx
Franks (AZ)
Frelinghuysen
Gallegly
Garrett (NJ)
Gerlach
Gingrey (GA)
Gohmert
Goodlatte
Granger
Graves
Griffith
Guthrie
Hall (TX)
Harper
Hastings (WA)
Heller
Hensarling
Herger
Hoekstra
Holden
Hunter
Inglis
Issa
Jenkins
Johnson (IL)
Johnson, Sam
Jones
Jordan (OH)
King (IA)
King (NY)
Kingston
Kirk
Kline (MN)
Lamborn
Lance
Latham
LaTourette
Latta
Lee (NY)
Lewis (CA)
Linder
Lipinski
LoBiondo
Lucas
Luetkemeyer
Lummis
Lungren, Daniel E.
Mack
Manzullo
Marchant
Marshall
Matheson
McCarthy (CA)
McCaul
McClintock
McCotter
McHenry
McIntyre
McKeon
McMorris Rodgers
Melancon
Mica
Miller (FL)
Miller (MI)
Miller, Gary
Moran (KS)
Murphy, Tim
Myrick
Neugebauer
Nunes
Olson
Paul
Paulsen
Pence
Peterson
Petri
Pitts
Platts
Poe (TX)
Posey
Price (GA)
Putnam
Radanovich
Rehberg
Reichert
Roe (TN)
Rogers (AL)
Rogers (KY)
Rogers (MI)
Rohrabacher
Rooney
Ros-Lehtinen
Roskam
Ross
Royce
Ryan (WI)
Scalise
Schmidt
Schock
Sensenbrenner
Sessions
Shadegg
Shimkus
Shuler
Shuster
Simpson
Skelton
Smith (NE)
Smith (NJ)
Smith (TX)
Souder
Stearns
Sullivan
Taylor
Terry
Thompson (PA)
Thornberry
Tiahrt
Tiberi
Turner
Upton
Walden
Wamp
Westmoreland
Whitfield
Wilson (SC)
Wittman
Wolf
Young (AK)
Young (FL)
NOES--232
Ackerman
Adler (NJ)
Andrews
Arcuri
Baca
Baird
Baldwin
Bean
Becerra
Berkley
Berman
Bishop (GA)
Bishop (NY)
Blumenauer
Boccieri
Boswell
Boucher
Boyd
Brady (PA)
Braley (IA)
Brown, Corrine
Butterfield
Capps
Capuano
Cardoza
Carnahan
Carney
Carson (IN)
Castor (FL)
Chu
Clarke
Clay
Cleaver
Clyburn
Cohen
Connolly (VA)
Conyers
Cooper
Costa
Courtney
Crowley
Cuellar
Cummings
Dahlkemper
Davis (AL)
Davis (CA)
Davis (IL)
DeFazio
DeGette
Delahunt
DeLauro
Dicks
Dingell
Doggett
Doyle
Driehaus
Edwards (MD)
Edwards (TX)
Ellison
Ellsworth
Engel
Eshoo
Etheridge
Farr
Fattah
Filner
Foster
Frank (MA)
Fudge
Garamendi
Giffords
Gonzalez
Gordon (TN)
Grayson
Green, Al
Green, Gene
Grijalva
Gutierrez
Hall (NY)
Halvorson
Hare
Harman
Hastings (FL)
Heinrich
Herseth Sandlin
Higgins
Hill
Himes
Hinchey
Hinojosa
Hirono
Hodes
Holt
Honda
Hoyer
Inslee
Israel
Jackson (IL)
Jackson Lee (TX)
Johnson (GA)
Johnson, E. B.
Kagen
Kanjorski
Kaptur
Kennedy
Kildee
Kilpatrick (MI)
Kilroy
Kind
Kirkpatrick (AZ)
Kissell
Klein (FL)
Kosmas
Kratovil
Kucinich
Langevin
Larsen (WA)
Larson (CT)
Lee (CA)
Levin
Lewis (GA)
Loebsack
Lofgren, Zoe
Lowey
Lujan
Lynch
Maffei
Maloney
Markey (CO)
Markey (MA)
Matsui
McCarthy (NY)
McCollum
McDermott
McGovern
McMahon
McNerney
Meek (FL)
Meeks (NY)
Michaud
Miller (NC)
Miller, George
Minnick
Mitchell
Mollohan
Moore (KS)
Moore (WI)
Moran (VA)
Murphy (CT)
Murphy (NY)
Murphy, Patrick
Nadler (NY)
Napolitano
Neal (MA)
Nye
Oberstar
Obey
Olver
[[Page H2169]]
Ortiz
Owens
Pallone
Pascrell
Pastor (AZ)
Payne
Pelosi
Perlmutter
Perriello
Peters
Pingree (ME)
Polis (CO)
Pomeroy
Price (NC)
Quigley
Rahall
Rangel
Reyes
Richardson
Rodriguez
Rothman (NJ)
Roybal-Allard
Ruppersberger
Rush
Ryan (OH)
Salazar
Sanchez, Linda T.
Sanchez, Loretta
Sarbanes
Schakowsky
Schauer
Schiff
Schrader
Schwartz
Scott (GA)
Scott (VA)
Serrano
Sestak
Shea-Porter
Sherman
Sires
Slaughter
Smith (WA)
Snyder
Space
Speier
Spratt
Stark
Stupak
Sutton
Tanner
Teague
Thompson (CA)
Thompson (MS)
Tierney
Titus
Tonko
Towns
Tsongas
Van Hollen
Velazquez
Visclosky
Walz
Wasserman Schultz
Waters
Watson
Watt
Waxman
Weiner
Welch
Wilson (OH)
Woolsey
Wu
Yarmuth
{time} 2319
So the motion to recommit was rejected.
The result of the vote was announced as above recorded.
The SPEAKER pro tempore. The question is on the passage of the bill.
The question was taken; and the Speaker pro tempore announced that
the ayes appeared to have it.
Recorded Vote
Mr. DINGELL. Mr. Speaker, I demand a recorded vote.
A recorded vote was ordered.
The SPEAKER pro tempore. Pursuant to clause 8 of rule XX, this 15-
minute vote on passage of the bill will be followed by 5-minute votes
on motions to suspend the rules with regard to House Resolution 1099
and House Resolution 1119.
The vote was taken by electronic device, and there were--ayes 220,
noes 211, not voting 0, as follows:
[Roll No. 167]
AYES--220
Ackerman
Andrews
Baca
Baird
Baldwin
Bean
Becerra
Berkley
Berman
Bishop (GA)
Bishop (NY)
Blumenauer
Boccieri
Boswell
Boyd
Brady (PA)
Braley (IA)
Brown, Corrine
Butterfield
Capps
Capuano
Cardoza
Carnahan
Carney
Carson (IN)
Castor (FL)
Chu
Clarke
Clay
Cleaver
Clyburn
Cohen
Connolly (VA)
Conyers
Costa
Costello
Courtney
Crowley
Cuellar
Cummings
Dahlkemper
Davis (CA)
Davis (IL)
DeFazio
DeGette
Delahunt
DeLauro
Dicks
Dingell
Doggett
Donnelly (IN)
Doyle
Driehaus
Edwards (MD)
Ellison
Ellsworth
Engel
Eshoo
Etheridge
Farr
Fattah
Filner
Foster
Frank (MA)
Fudge
Garamendi
Giffords
Gonzalez
Gordon (TN)
Grayson
Green, Al
Green, Gene
Grijalva
Gutierrez
Hall (NY)
Halvorson
Hare
Harman
Hastings (FL)
Heinrich
Higgins
Hill
Himes
Hinchey
Hinojosa
Hirono
Hodes
Holt
Honda
Hoyer
Inslee
Israel
Jackson (IL)
Jackson Lee (TX)
Johnson (GA)
Johnson, E. B.
Kagen
Kanjorski
Kaptur
Kennedy
Kildee
Kilpatrick (MI)
Kilroy
Kind
Kirkpatrick (AZ)
Klein (FL)
Kosmas
Kucinich
Langevin
Larsen (WA)
Larson (CT)
Lee (CA)
Levin
Lewis (GA)
Lipinski
Loebsack
Lofgren, Zoe
Lowey
Lujan
Lynch
Maffei
Maloney
Markey (CO)
Markey (MA)
Matsui
McCarthy (NY)
McCollum
McDermott
McGovern
McNerney
Meek (FL)
Meeks (NY)
Michaud
Miller (NC)
Miller, George
Mitchell
Mollohan
Moore (KS)
Moore (WI)
Moran (VA)
Murphy (CT)
Murphy (NY)
Murphy, Patrick
Nadler (NY)
Napolitano
Neal (MA)
Oberstar
Obey
Olver
Ortiz
Owens
Pallone
Pascrell
Pastor (AZ)
Payne
Pelosi
Perlmutter
Perriello
Peters
Pingree (ME)
Polis (CO)
Pomeroy
Price (NC)
Quigley
Rahall
Rangel
Reyes
Richardson
Rodriguez
Rothman (NJ)
Roybal-Allard
Ruppersberger
Rush
Ryan (OH)
Salazar
Sanchez, Linda T.
Sanchez, Loretta
Sarbanes
Schakowsky
Schauer
Schiff
Schrader
Schwartz
Scott (GA)
Scott (VA)
Serrano
Sestak
Shea-Porter
Sherman
Sires
Slaughter
Smith (WA)
Snyder
Speier
Spratt
Stark
Stupak
Sutton
Thompson (CA)
Thompson (MS)
Tierney
Titus
Tonko
Towns
Tsongas
Van Hollen
Velazquez
Visclosky
Walz
Wasserman Schultz
Waters
Watson
Watt
Waxman
Weiner
Welch
Wilson (OH)
Woolsey
Wu
Yarmuth
NOES--211
Aderholt
Adler (NJ)
Akin
Alexander
Altmire
Arcuri
Austria
Bachmann
Bachus
Barrett (SC)
Barrow
Bartlett
Barton (TX)
Berry
Biggert
Bilbray
Bilirakis
Bishop (UT)
Blackburn
Blunt
Boehner
Bonner
Bono Mack
Boozman
Boren
Boucher
Boustany
Brady (TX)
Bright
Broun (GA)
Brown (SC)
Brown-Waite, Ginny
Buchanan
Burgess
Burton (IN)
Buyer
Calvert
Camp
Campbell
Cantor
Cao
Capito
Carter
Cassidy
Castle
Chaffetz
Chandler
Childers
Coble
Coffman (CO)
Cole
Conaway
Cooper
Crenshaw
Culberson
Davis (AL)
Davis (KY)
Davis (TN)
Deal (GA)
Dent
Diaz-Balart, L.
Diaz-Balart, M.
Dreier
Duncan
Edwards (TX)
Ehlers
Emerson
Fallin
Flake
Fleming
Forbes
Fortenberry
Foxx
Franks (AZ)
Frelinghuysen
Gallegly
Garrett (NJ)
Gerlach
Gingrey (GA)
Gohmert
Goodlatte
Granger
Graves
Griffith
Guthrie
Hall (TX)
Harper
Hastings (WA)
Heller
Hensarling
Herger
Herseth Sandlin
Hoekstra
Holden
Hunter
Inglis
Issa
Jenkins
Johnson (IL)
Johnson, Sam
Jones
Jordan (OH)
King (IA)
King (NY)
Kingston
Kirk
Kissell
Kline (MN)
Kratovil
Lamborn
Lance
Latham
LaTourette
Latta
Lee (NY)
Lewis (CA)
Linder
LoBiondo
Lucas
Luetkemeyer
Lummis
Lungren, Daniel E.
Mack
Manzullo
Marchant
Marshall
Matheson
McCarthy (CA)
McCaul
McClintock
McCotter
McHenry
McIntyre
McKeon
McMahon
McMorris Rodgers
Melancon
Mica
Miller (FL)
Miller (MI)
Miller, Gary
Minnick
Moran (KS)
Murphy, Tim
Myrick
Neugebauer
Nunes
Nye
Olson
Paul
Paulsen
Pence
Peterson
Petri
Pitts
Platts
Poe (TX)
Posey
Price (GA)
Putnam
Radanovich
Rehberg
Reichert
Roe (TN)
Rogers (AL)
Rogers (KY)
Rogers (MI)
Rohrabacher
Rooney
Ros-Lehtinen
Roskam
Ross
Royce
Ryan (WI)
Scalise
Schmidt
Schock
Sensenbrenner
Sessions
Shadegg
Shimkus
Shuler
Shuster
Simpson
Skelton
Smith (NE)
Smith (NJ)
Smith (TX)
Souder
Space
Stearns
Sullivan
Tanner
Taylor
Teague
Terry
Thompson (PA)
Thornberry
Tiahrt
Tiberi
Turner
Upton
Walden
Wamp
Westmoreland
Whitfield
Wilson (SC)
Wittman
Wolf
Young (AK)
Young (FL)
{time} 2337
So the bill was passed.
The result of the vote was announced as above recorded.
A motion to reconsider was laid on the table.
____________________