[Congressional Record (Bound Edition), Volume 155 (2009), Part 23]
[Senate]
[Pages 31815-31837]
[From the U.S. Government Publishing Office, www.gpo.gov]




                           TEXT OF AMENDMENTS

  SA 3219. Mr. CARDIN submitted an amendment intended to be proposed to 
amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       On page 396, between lines 8 and 9, insert the following:

                    Subtitle H--Patient Protections

                     PART I--IMPROVING MANAGED CARE

                 Subpart A--Utilization Review; Claims

     SEC. 1601. PROCEDURES FOR INITIAL CLAIMS FOR BENEFITS AND 
                   PRIOR AUTHORIZATION DETERMINATIONS.

       (a) Procedures of Initial Claims for Benefits.--
       (1) In general.--A group health plan, or health insurance 
     issuer offering health insurance coverage, shall--
       (A) make a determination on an initial claim for benefits 
     by a participant, beneficiary, or enrollee (or authorized 
     representative) regarding payment or coverage for items or 
     services under the terms and conditions of the plan or 
     coverage involved, including any cost-sharing amount that the 
     participant, beneficiary, or enrollee is required to pay with 
     respect to such claim for benefits; and
       (B) notify a participant, beneficiary, or enrollee (or 
     authorized representative) and the treating health care 
     professional involved regarding a determination on an initial 
     claim for benefits made under the terms and conditions of the 
     plan or coverage, including any cost-sharing amounts that the 
     participant, beneficiary, or enrollee may be required to make 
     with respect to such claim for benefits.
       (2) Access to information.--
       (A) Timely provision of necessary information.--With 
     respect to an initial claim for benefits, the participant, 
     beneficiary, or enrollee (or authorized representative) and 
     the treating health care professional (if any) shall provide 
     the plan or issuer with access to information requested by 
     the plan or issuer that is necessary to make a determination 
     relating to the claim. Such access shall be provided not 
     later than 5 days after the date on which the request for 
     information is received
       (B) Limited effect of failure on plan or issuer's 
     obligations.--Failure of the participant, beneficiary, or 
     enrollee to comply with the requirements of subparagraph (A) 
     shall not remove the obligation of the plan or issuer to make 
     a decision in accordance with the medical exigencies of the 
     case and as soon as possible, based on the available 
     information, and failure to comply with the time limit 
     established by this paragraph shall not remove the obligation 
     of the plan or issuer to comply with the requirements of this 
     section.
       (3) Oral requests.--In the case of a claim for benefits 
     involving an expedited or concurrent determination, a 
     participant, beneficiary, or enrollee (or authorized 
     representative) may make an initial claim for benefits 
     orally, but a group health plan, or health insurance issuer 
     offering health insurance coverage, may require that the 
     participant, beneficiary, or enrollee (or authorized 
     representative) provide written confirmation of such request 
     in a timely manner on a form provided by the plan or issuer. 
     In the case of such an oral request for benefits, the making 
     of the request (and the timing of such request) shall be 
     treated as the making at that time of a claims for such 
     benefits without regard to whether and when a written 
     confirmation of such request is made.
       (b) Notice of a Denial of a Claim for Benefits.--Written 
     notice of a denial made under an initial claim for benefits 
     shall be issued to the participant, beneficiary, or enrollee 
     (or authorized representative) and the treating health care 
     professional in accordance with the medical exigencies of the 
     case and as soon as possible, but in no case later than 2 
     days after the date of the determination.
       (c) Requirements of Notice of Determinations.--The written 
     notice of a denial of a claim for benefits determination 
     under subsection (b) shall be provided in printed form and 
     written in a manner calculated to be understood by the 
     participant, beneficiary, or enrollee and shall include--
       (1) the specific reasons for the determination (including a 
     summary of the clinical or scientific evidence used in making 
     the determination); and
       (2) the procedures for obtaining additional information 
     concerning the determination.
       (d) Definitions.--For purposes of this part:
       (1) Authorized representative.--The term ``authorized 
     representative'' means, with respect to an individual who is 
     a participant, beneficiary, or enrollee, any health care 
     professional or other person acting on behalf of the 
     individual with the individual's consent or without such 
     consent if the individual is medically unable to provide such 
     consent.
       (2) Claim for benefits.--The term ``claim for benefits'' 
     means any request for coverage (including authorization of 
     coverage), for eligibility, or for payment in whole or in 
     part, for an item or service under a group health plan or 
     health insurance coverage.
       (3) Denial of claim for benefits.--The term ``denial'' 
     means, with respect to a claim for benefits, a denial (in 
     whole or in part) of, or a failure to act on a timely basis 
     upon, the claim for benefits and includes a failure to 
     provide benefits (including items and services) required to 
     be provided under this part.
       (4) Treating health care professional.--The term ``treating 
     health care professional'' means, with respect to services to 
     be provided to a participant, beneficiary, or enrollee, a 
     health care professional who is primarily responsible for 
     delivering those services to the participant, beneficiary, or 
     enrollee.

                       Subpart B--Access to Care

     SEC. 1611. CHOICE OF HEALTH CARE PROFESSIONAL.

       (a) Primary Care.--If a group health plan, or a health 
     insurance issuer that offers 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) Specialists.--
       (1) In general.--Subject to paragraph (2), a group health 
     plan and a health insurance issuer that offers health 
     insurance coverage shall permit each participant, 
     beneficiary, or enrollee to receive medically necessary and 
     appropriate specialty care, pursuant to appropriate referral 
     procedures, from any

[[Page 31816]]

     qualified participating health care professional who is 
     available to accept such individual for such care.
       (2) Limitation.--Paragraph (1) shall not apply to specialty 
     care if the plan or issuer clearly informs participants, 
     beneficiaries, and enrollees of the limitations on choice of 
     participating health care professionals with respect to such 
     care.
       (3) Construction.--Nothing in this subsection shall be 
     construed as affecting the application of section 114 
     (relating to access to specialty care).

     SEC. 1612. ACCESS TO EMERGENCY CARE.

       (a) Coverage of Emergency Services.--
       (1) In general.--If a group health plan, or health 
     insurance coverage offered by a 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 the Public Health Service 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 section:
       (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)).
       (b) Reimbursement for Maintenance Care and Post-
     Stabilization Care.--A group health plan, and health 
     insurance coverage offered by a health insurance issuer, must 
     provide reimbursement for maintenance care and post-
     stabilization care in accordance with the requirements of 
     section 1852(d)(2) of the Social Security Act (42 U.S.C. 
     1395w-22(d)(2)). Such reimbursement shall be provided in a 
     manner consistent with subsection (a)(1)(C).
       (c) Coverage of Emergency Ambulance Services.--
       (1) In general.--If a group health plan, or health 
     insurance coverage provided by a health insurance issuer, 
     provides any benefits with respect to ambulance services and 
     emergency services, the plan or issuer shall cover emergency 
     ambulance services (as defined in paragraph (2)) furnished 
     under the plan or coverage under the same terms and 
     conditions under subparagraphs (A) through (D) of subsection 
     (a)(1) under which coverage is provided for emergency 
     services.
       (2) Emergency ambulance services.--For purposes of this 
     subsection, the term ``emergency ambulance services'' means 
     ambulance services (as defined for purposes of section 
     1861(s)(7) of the Social Security Act) furnished to transport 
     an individual who has an emergency medical condition (as 
     defined in subsection (a)(2)(A)) to a hospital for the 
     receipt of emergency services (as defined in subsection 
     (a)(2)(B)) in a case in which the emergency services are 
     covered under the plan or coverage pursuant to subsection 
     (a)(1) and a prudent layperson, with an average knowledge of 
     health and medicine, could reasonably expect that the absence 
     of such transport would result in placing the health of the 
     individual in serious jeopardy, serious impairment of bodily 
     function, or serious dysfunction of any bodily organ or part.

     SEC. 1613. TIMELY ACCESS TO SPECIALISTS.

       (a) Timely Access.--
       (1) In general.--A group health plan or health insurance 
     issuer offering health insurance coverage shall ensure that 
     participants, beneficiaries, and enrollees receive timely 
     access to specialists who are appropriate to the condition 
     of, and accessible to, the participant, beneficiary, or 
     enrollee, when such specialty care is a covered benefit under 
     the plan or coverage.
       (2) Rule of construction.--Nothing in paragraph (1) shall 
     be construed--
       (A) to require the coverage under a group health plan or 
     health insurance coverage of benefits or services;
       (B) to prohibit a plan or issuer from including providers 
     in the network only to the extent necessary to meet the needs 
     of the plan's or issuer's participants, beneficiaries, or 
     enrollees;
       (C) to override any State licensure or scope-of-practice 
     law; or
       (D) to override the normal community standards, taking into 
     account the geographic location of such community, regarding 
     timely access to specialists.
       (3) Access to certain providers.--
       (A) In general.--With respect to specialty care under this 
     section, if a participating specialist is not available and 
     qualified to provide such care to the participant, 
     beneficiary, or enrollee, the plan or issuer shall provide 
     for coverage of such care by a nonparticipating specialist.
       (B) Treatment of nonparticipating providers.--If a 
     participant, beneficiary, or enrollee receives care from a 
     nonparticipating specialist pursuant to subparagraph (A), 
     such specialty care shall be provided at no additional cost 
     to the participant, beneficiary, or enrollee beyond what the 
     participant, beneficiary, or enrollee would otherwise pay for 
     such specialty care if provided by a participating 
     specialist.
       (b) Referrals.--
       (1) Authorization.--Subject to subsection (a)(1), a group 
     health plan or health insurance issuer may require an 
     authorization in order to obtain coverage for specialty 
     services under this section. Any such authorization--
       (A) shall be for an appropriate duration of time or number 
     of referrals, including an authorization for a standing 
     referral where appropriate; and
       (B) may not be refused solely because the authorization 
     involves services of a nonparticipating specialist (described 
     in subsection (a)(3)).
       (2) Referrals for ongoing special conditions.--
       (A) In general.--Subject to subsection (a)(1), a group 
     health plan or health insurance issuer shall permit a 
     participant, beneficiary, or enrollee who has an ongoing 
     special condition (as defined in subparagraph (B)) to receive 
     a referral to a specialist for the treatment of such 
     condition and such specialist may authorize such referrals, 
     procedures, tests, and other medical services with respect to 
     such condition, or coordinate the care for such condition, 
     subject to the terms of a treatment plan (if any) referred to 
     in subsection (c) with respect to the condition, if such 
     specialist agrees otherwise to 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) Ongoing special condition defined.--In this subsection, 
     the term ``ongoing special condition'' means a condition or 
     disease that--
       (i) is life-threatening, degenerative, potentially 
     disabling, or congenital; and
       (ii) requires specialized medical care over a prolonged 
     period of time.
       (c) Treatment Plans.--
       (1) In general.--A group health plan or health insurance 
     issuer may require that the specialty care be provided--
       (A) pursuant to a treatment plan, but only if the treatment 
     plan--
       (i) is developed by the specialist, in consultation with 
     the case manager or primary care provider, and the 
     participant, beneficiary, or enrollee, and
       (ii) is approved by the plan or issuer in a timely manner, 
     if the plan or issuer requires such approval; and
       (B) in accordance with applicable quality assurance and 
     utilization review standards of the plan or issuer.
       (2) Notification.--Nothing in paragraph (1) shall be 
     construed as prohibiting a plan or issuer from requiring the 
     specialist to provide the plan or issuer with regular updates 
     on the specialty care provided, as well as all other 
     reasonably necessary medical information.
       (d) Specialist Defined.--For purposes of this section, the 
     term ``specialist'' means, with respect to the condition of 
     the participant, beneficiary, or enrollee, a health care 
     professional, facility, or center that has adequate expertise 
     through appropriate training

[[Page 31817]]

     and experience (including, in the case of a child, 
     appropriate pediatric expertise) to provide high quality care 
     in treating the condition.

     SEC. 1614. ACCESS TO PEDIATRIC CARE.

       (a) 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, 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.
       (b) Construction.--Nothing in subsection (a) 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.

     SEC. 1615. PATIENT ACCESS TO OBSTETRICAL AND GYNECOLOGICAL 
                   CARE.

       (a) General Rights.--
       (1) Direct access.--A group health plan, or health 
     insurance issuer offering health insurance coverage, 
     described in subsection (b) may not require authorization or 
     referral by the plan, issuer, or any person (including a 
     primary care provider described in subsection (b)(2)) 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.
       (2) Obstetrical and gynecological care.--A group health 
     plan or health insurance issuer described in subsection (b) 
     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 paragraph (1), by a participating 
     health care professional who specializes in obstetrics or 
     gynecology as the authorization of the primary care provider.
       (b) Application of Section.--A group health plan, or health 
     insurance issuer offering health insurance coverage, 
     described in this subsection is a group health plan or 
     coverage that--
       (1) provides coverage for obstetric or gynecologic care; 
     and
       (2) requires the designation by a participant, beneficiary, 
     or enrollee of a participating primary care provider.
       (c) Construction.--Nothing in subsection (a) shall be 
     construed to--
       (1) 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
       (2) 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.

     SEC. 1616. CONTINUITY OF CARE.

       (a) Termination of Provider.--
       (1) In general.--If--
       (A) a contract between a group health plan, or a health 
     insurance issuer offering health insurance coverage, and a 
     treating health care provider is terminated (as defined in 
     subsection (e)(4)), or
       (B) benefits or coverage provided by a health care provider 
     are terminated because of a change in the terms of provider 
     participation in such plan or coverage,

     the plan or issuer shall meet the requirements of paragraph 
     (3) with respect to each continuing care patient.
       (2) Treatment of termination of contract with health 
     insurance issuer.--If a contract for the provision of health 
     insurance coverage between a group health plan and a health 
     insurance issuer is terminated and, as a result of such 
     termination, coverage of services of a health care provider 
     is terminated with respect to an individual, the provisions 
     of paragraph (1) (and the succeeding provisions of this 
     section) shall apply under the plan in the same manner as if 
     there had been a contract between the plan and the provider 
     that had been terminated, but only with respect to benefits 
     that are covered under the plan after the contract 
     termination.
       (3) Requirements.--The requirements of this paragraph are 
     that the plan or issuer--
       (A) notify the continuing care patient involved, or arrange 
     to have the patient notified pursuant to subsection (d)(2), 
     on a timely basis of the termination described in paragraph 
     (1) (or paragraph (2), if applicable) and the right to elect 
     continued transitional care from the provider under this 
     section;
       (B) provide the patient with an opportunity to notify the 
     plan or issuer of the patient's need for transitional care; 
     and
       (C) subject to subsection (c), permit the patient to elect 
     to continue to be covered with respect to the course of 
     treatment by such provider with the provider's consent during 
     a transitional period (as provided for under subsection (b)).
       (4) Continuing care patient.--For purposes of this section, 
     the term ``continuing care patient'' means a participant, 
     beneficiary, or enrollee who--
       (A) is undergoing a course of treatment for a serious and 
     complex condition from the provider at the time the plan or 
     issuer receives or provides notice of provider, benefit, or 
     coverage termination described in paragraph (1) (or paragraph 
     (2), if applicable);
       (B) is undergoing a course of institutional or inpatient 
     care from the provider at the time of such notice;
       (C) is scheduled to undergo non-elective surgery from the 
     provider at the time of such notice;
       (D) is pregnant and undergoing a course of treatment for 
     the pregnancy from the provider at the time of such notice; 
     or
       (E) is or was determined to be terminally ill (as 
     determined under section 1861(dd)(3)(A) of the Social 
     Security Act) at the time of such notice, but only with 
     respect to a provider that was treating the terminal illness 
     before the date of such notice.
       (b) Transitional Periods.--
       (1) Serious and complex conditions.--The transitional 
     period under this subsection with respect to a continuing 
     care patient described in subsection (a)(4)(A) shall extend 
     for up to 90 days (as determined by the treating health care 
     professional) from the date of the notice described in 
     subsection (a)(3)(A).
       (2) Institutional or inpatient care.--The transitional 
     period under this subsection for a continuing care patient 
     described in subsection (a)(4)(B) shall extend until the 
     earlier of--
       (A) the expiration of the 90-day period beginning on the 
     date on which the notice under subsection (a)(3)(A) is 
     provided; or
       (B) the date of discharge of the patient from such care or 
     the termination of the period of institutionalization, or, if 
     later, the date of completion of reasonable follow-up care.
       (3) Scheduled non-elective surgery.--The transitional 
     period under this subsection for a continuing care patient 
     described in subsection (a)(4)(C) shall extend until the 
     completion of the surgery involved and post-surgical follow-
     up care relating to the surgery and occurring within 90 days 
     after the date of the surgery.
       (4) Pregnancy.--The transitional period under this 
     subsection for a continuing care patient described in 
     subsection (a)(4)(D) shall extend through the provision of 
     post-partum care directly related to the delivery.
       (5) Terminal illness.--The transitional period under this 
     subsection for a continuing care patient described in 
     subsection (a)(4)(E) shall extend for the remainder of the 
     patient's life for care that is directly related to the 
     treatment of the terminal illness or its medical 
     manifestations.
       (c) Permissible Terms and Conditions.--A group health plan 
     or health insurance issuer may condition coverage of 
     continued treatment by a provider under this section upon the 
     provider agreeing to the following terms and conditions:
       (1) The treating health care provider agrees to accept 
     reimbursement from the plan or issuer and continuing care 
     patient involved (with respect to cost-sharing) at the rates 
     applicable prior to the start of the transitional period as 
     payment in full (or, in the case described in subsection 
     (a)(2), at the rates applicable under the replacement plan or 
     coverage after the date of the termination of the contract 
     with the group health plan or health insurance issuer) and 
     not to impose cost-sharing with respect to the patient in an 
     amount that would exceed the cost-sharing that could have 
     been imposed if the contract referred to in subsection (a)(1) 
     had not been terminated.
       (2) The treating health care provider agrees to adhere to 
     the quality assurance standards of the plan or issuer 
     responsible for payment under paragraph (1) and to provide to 
     such plan or issuer necessary medical information related to 
     the care provided.
       (3) The treating health care provider agrees otherwise to 
     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.
       (d) Rules of Construction.--Nothing in this section shall 
     be construed--
       (1) to require the coverage of benefits which would not 
     have been covered if the provider involved remained a 
     participating provider; or
       (2) with respect to the termination of a contract under 
     subsection (a) to prevent a group health plan or health 
     insurance issuer from requiring that the health care 
     provider--
       (A) notify participants, beneficiaries, or enrollees of 
     their rights under this section; or
       (B) provide the plan or issuer with the name of each 
     participant, beneficiary, or enrollee who the provider 
     believes is a continuing care patient.
       (e) Definitions.--In this section:
       (1) Contract.--The term ``contract'' includes, with respect 
     to a plan or issuer and a

[[Page 31818]]

     treating health care provider, a contract between such plan 
     or issuer and an organized network of providers that includes 
     the treating health care provider, and (in the case of such a 
     contract) the contract between the treating health care 
     provider and the organized network.
       (2) Health care provider.--The term ``health care 
     provider'' or ``provider'' means--
       (A) any individual who is engaged in the delivery of health 
     care services in a State and who is required by State law or 
     regulation to be licensed or certified by the State to engage 
     in the delivery of such services in the State; and
       (B) any entity that is engaged in the delivery of health 
     care services in a State and that, if it is required by State 
     law or regulation to be licensed or certified by the State to 
     engage in the delivery of such services in the State, is so 
     licensed.
       (3) Serious and complex condition.--The term ``serious and 
     complex condition'' means, with respect to a participant, 
     beneficiary, or enrollee under the plan or coverage--
       (A) in the case of an acute illness, a condition that is 
     serious enough to require specialized medical treatment to 
     avoid the reasonable possibility of death or permanent harm; 
     or
       (B) in the case of a chronic illness or condition, is an 
     ongoing special condition (as defined in section (b)(2)(B)).
       (4) Terminated.--The term ``terminated'' includes, with 
     respect to a contract, the expiration or nonrenewal of the 
     contract, but does not include a termination of the contract 
     for failure to meet applicable quality standards or for 
     fraud.

         Subpart C--Protecting the Doctor-Patient Relationship

     SEC. 1621. PROHIBITION OF INTERFERENCE WITH CERTAIN MEDICAL 
                   COMMUNICATIONS.

       (a) General Rule.--The provisions of any contract or 
     agreement, or the operation of any contract or agreement, 
     between a group health plan or health insurance issuer in 
     relation to health insurance coverage (including any 
     partnership, association, or other organization that enters 
     into or administers such a contract or agreement) and a 
     health care provider (or group of health care providers) 
     shall not prohibit or otherwise restrict a health care 
     professional from advising such a participant, beneficiary, 
     or enrollee who is a patient of the professional about the 
     health status of the individual or medical care or treatment 
     for the individual's condition or disease, regardless of 
     whether benefits for such care or treatment are provided 
     under the plan or coverage, if the professional is acting 
     within the lawful scope of practice.
       (b) Nullification.--Any contract provision or agreement 
     that restricts or prohibits medical communications in 
     violation of subsection (a) shall be null and void.

                         Subpart D--Definitions

     SEC. 1631. DEFINITIONS.

       (a) Incorporation of General Definitions.--Except as 
     otherwise provided, the provisions of section 2791 of the 
     Public Health Service Act shall apply for purposes of this 
     part in the same manner as they apply for purposes of title 
     XXVII of such Act.
       (b) Secretary.--Except as otherwise provided, the term 
     ``Secretary'' means the Secretary of Health and Human 
     Services, in consultation with the Secretary of Labor and the 
     term ``appropriate Secretary'' means the Secretary of Health 
     and Human Services in relation to carrying out this part 
     under sections 2706 and 2751 of the Public Health Service Act 
     and the Secretary of Labor in relation to carrying out this 
     part under section 713 of the Employee Retirement Income 
     Security Act of 1974.
       (c) Additional Definitions.--For purposes of this part:
       (1) Applicable authority.--The term ``applicable 
     authority'' means--
       (A) in the case of a group health plan, the Secretary of 
     Health and Human Services and the Secretary of Labor; and
       (B) in the case of a health insurance issuer with respect 
     to a specific provision of this part, the applicable State 
     authority (as defined in section 2791(d) of the Public Health 
     Service Act), or the Secretary of Health and Human Services, 
     if such Secretary is enforcing such provision under section 
     2722(a)(2) or 2761(a)(2) of the Public Health Service Act.
       (2) Enrollee.--The term ``enrollee'' means, with respect to 
     health insurance coverage offered by a health insurance 
     issuer, an individual enrolled with the issuer to receive 
     such coverage.
       (3) Group health plan.--The term ``group health plan'' has 
     the meaning given such term in section 733(a) of the Employee 
     Retirement Income Security Act of 1974, except that such term 
     includes a employee welfare benefit plan treated as a group 
     health plan under section 732(d) of such Act or defined as 
     such a plan under section 607(1) of such Act.
       (4) Health care professional.--The term ``health care 
     professional'' means an individual who is licensed, 
     accredited, or certified under State law to provide specified 
     health care services and who is operating within the scope of 
     such licensure, accreditation, or certification.
       (5) Health care provider.--The term ``health care 
     provider'' includes a physician or other health care 
     professional, as well as an institutional or other facility 
     or agency that provides health care services and that is 
     licensed, accredited, or certified to provide health care 
     items and services under applicable State law.
       (6) Network.--The term ``network'' means, with respect to a 
     group health plan or health insurance issuer offering health 
     insurance coverage, the participating health care 
     professionals and providers through whom the plan or issuer 
     provides health care items and services to participants, 
     beneficiaries, or enrollees.
       (7) Nonparticipating.--The term ``nonparticipating'' means, 
     with respect to a health care provider that provides health 
     care items and services to a participant, beneficiary, or 
     enrollee under group health plan or health insurance 
     coverage, a health care provider that is not a participating 
     health care provider with respect to such items and services.
       (8) Participating.--The term ``participating'' means, with 
     respect to a health care provider that provides health care 
     items and services to a participant, beneficiary, or enrollee 
     under group health plan or health insurance coverage offered 
     by a health insurance issuer, a health care provider that 
     furnishes such items and services under a contract or other 
     arrangement with the plan or issuer.
       (9) Prior authorization.--The term ``prior authorization'' 
     means the process of obtaining prior approval from a health 
     insurance issuer or group health plan for the provision or 
     coverage of medical services.
       (10) Terms and conditions.--The term ``terms and 
     conditions'' includes, with respect to a group health plan or 
     health insurance coverage, requirements imposed under this 
     part with respect to the plan or coverage.

     SEC. 1632. PREEMPTION; STATE FLEXIBILITY; CONSTRUCTION.

       (a) Continued Applicability of State Law With Respect to 
     Health Insurance Issuers.--
       (1) In general.--Subject to paragraph (2), this part shall 
     not be construed to supersede any provision of State law 
     which establishes, implements, or continues in effect any 
     standard or requirement solely relating to health insurance 
     issuers (in connection with group health insurance coverage 
     or otherwise) except to the extent that such standard or 
     requirement prevents the application of a requirement of this 
     part.
       (2) Continued preemption with respect to group health 
     plans.--Nothing in this part shall be construed to affect or 
     modify the provisions of section 514 of the Employee 
     Retirement Income Security Act of 1974 with respect to group 
     health plans.
       (3) Construction.--In applying this section, a State law 
     that provides for equal access to, and availability of, all 
     categories of licensed health care providers and services 
     shall not be treated as preventing the application of any 
     requirement of this part.
       (b) Application of Substantially Compliant State Laws.--
       (1) In general.--In the case of a State law that imposes, 
     with respect to health insurance coverage offered by a health 
     insurance issuer and with respect to a group health plan that 
     is a non-Federal governmental plan, a requirement that 
     substantially complies (within the meaning of subsection (c)) 
     with a patient protection requirement (as defined in 
     paragraph (3)) and does not prevent the application of other 
     requirements under this subtitle (except in the case of other 
     substantially compliant requirements), in applying the 
     requirements of this part under section 2720 and 2754 (as 
     applicable) of the Public Health Service Act (as added by 
     part II), subject to subsection (a)(2)--
       (A) the State law shall not be treated as being superseded 
     under subsection (a); and
       (B) the State law shall apply instead of the patient 
     protection requirement otherwise applicable with respect to 
     health insurance coverage and non-Federal governmental plans.
       (2) Limitation.--In the case of a group health plan covered 
     under title I of the Employee Retirement Income Security Act 
     of 1974, paragraph (1) shall be construed to apply only with 
     respect to the health insurance coverage (if any) offered in 
     connection with the plan.
       (3) Definitions.--In this section:
       (A) Patient protection requirement.--The term ``patient 
     protection requirement'' means a requirement under this part, 
     and includes (as a single requirement) a group or related set 
     of requirements under a section or similar unit under this 
     part.
       (B) Substantially compliant.--The terms ``substantially 
     compliant'', substantially complies'', or ``substantial 
     compliance'' with respect to a State law, mean that the State 
     law has the same or similar features as the patient 
     protection requirements and has a similar effect.
       (c) Determinations of Substantial Compliance.--
       (1) Certification by states.--A State may submit to the 
     Secretary a certification that a State law provides for 
     patient protections that are at least substantially compliant

[[Page 31819]]

     with one or more patient protection requirements. Such 
     certification shall be accompanied by such information as may 
     be required to permit the Secretary to make the determination 
     described in paragraph (2)(A).
       (2) Review.--
       (A) In general.--The Secretary shall promptly review a 
     certification submitted under paragraph (1) with respect to a 
     State law to determine if the State law substantially 
     complies with the patient protection requirement (or 
     requirements) to which the law relates.
       (B) Approval deadlines.--
       (i) Initial review.--Such a certification is considered 
     approved unless the Secretary notifies the State in writing, 
     within 90 days after the date of receipt of the 
     certification, that the certification is disapproved (and the 
     reasons for disapproval) or that specified additional 
     information is needed to make the determination described in 
     subparagraph (A).
       (ii) Additional information.--With respect to a State that 
     has been notified by the Secretary under clause (i) that 
     specified additional information is needed to make the 
     determination described in subparagraph (A), the Secretary 
     shall make the determination within 60 days after the date on 
     which such specified additional information is received by 
     the Secretary.
       (3) Approval.--
       (A) In general.--The Secretary shall approve a 
     certification under paragraph (1) unless--
       (i) the State fails to provide sufficient information to 
     enable the Secretary to make a determination under paragraph 
     (2)(A); or
       (ii) the Secretary determines that the State law involved 
     does not provide for patient protections that substantially 
     comply with the patient protection requirement (or 
     requirements) to which the law relates.
       (B) State challenge.--A State that has a certification 
     disapproved by the Secretary under subparagraph (A) may 
     challenge such disapproval in the appropriate United States 
     district court.
       (C) Deference to states.--With respect to a certification 
     submitted under paragraph (1), the Secretary shall give 
     deference to the State's interpretation of the State law 
     involved and the compliance of the law with a patient 
     protection requirement.
       (D) Public notification.--The Secretary shall--
       (i) provide a State with a notice of the determination to 
     approve or disapprove a certification under this paragraph;
       (ii) promptly publish in the Federal Register a notice that 
     a State has submitted a certification under paragraph (1);
       (iii) promptly publish in the Federal Register the notice 
     described in clause (i) with respect to the State; and
       (iv) annually publish the status of all States with respect 
     to certifications.
       (4) Construction.--Nothing in this subsection shall be 
     construed as preventing the certification (and approval of 
     certification) of a State law under this subsection solely 
     because it provides for greater protections for patients than 
     those protections otherwise required to establish substantial 
     compliance.
       (5) Petitions.--
       (A) Petition process.--Effective on the date on which the 
     provisions of this subtitle become effective, as provided for 
     in section 1652, a group health plan, health insurance 
     issuer, participant, beneficiary, or enrollee may submit a 
     petition to the Secretary for an advisory opinion as to 
     whether or not a standard or requirement under a State law 
     applicable to the plan, issuer, participant, beneficiary, or 
     enrollee that is not the subject of a certification under 
     this subsection, is superseded under subsection (a)(1) 
     because such standard or requirement prevents the application 
     of a requirement of this part.
       (B) Opinion.--The Secretary shall issue an advisory opinion 
     with respect to a petition submitted under subparagraph (A) 
     within the 60-day period beginning on the date on which such 
     petition is submitted.
       (d) Definitions.--For purposes of this section:
       (1) State law.--The term ``State law'' includes all laws, 
     decisions, rules, regulations, or other State action having 
     the effect of law, of any State. A law of the United States 
     applicable only to the District of Columbia shall be treated 
     as a State law rather than a law of the United States.
       (2) State.--The term ``State'' includes a State, the 
     District of Columbia, Puerto Rico, the Virgin Islands, Guam, 
     American Samoa, the Northern Mariana Islands, any political 
     subdivisions of such, or any agency or instrumentality of 
     such.

     SEC. 1633. REGULATIONS.

       The Secretaries of Health and Human Services and Labor 
     shall issue such regulations as may be necessary or 
     appropriate to carry out this part. Such regulations shall be 
     issued consistent with section 104 of Health Insurance 
     Portability and Accountability Act of 1996. Such Secretaries 
     may promulgate any interim final rules as the Secretaries 
     determine are appropriate to carry out this part.

     SEC. 1634. INCORPORATION INTO PLAN OR COVERAGE DOCUMENTS.

       The requirements of this part with respect to a group 
     health plan or health insurance coverage are deemed to be 
     incorporated into, and made a part of, such plan or the 
     policy, certificate, or contract providing such coverage and 
     are enforceable under law as if directly included in the 
     documentation of such plan or such policy, certificate, or 
     contract.

 PART II--APPLICATION OF QUALITY CARE STANDARDS TO GROUP HEALTH PLANS 
   AND HEALTH INSURANCE COVERAGE UNDER THE PUBLIC HEALTH SERVICE ACT

     SEC. 1641. APPLICATION TO GROUP HEALTH PLANS AND GROUP HEALTH 
                   INSURANCE COVERAGE.

       (a) In General.--Subpart 2 of part A of title XXVII of the 
     Public Health Service Act, as amended by section 1001, is 
     further amended by adding at the end the following new 
     section:

     ``SEC. 2720. PATIENT PROTECTION STANDARDS.

       ``Each group health plan shall comply with patient 
     protection requirements under part I of subtitle H of title I 
     of the Patient Protection and Affordable Care Act, and each 
     health insurance issuer shall comply with patient protection 
     requirements under such part with respect to group health 
     insurance coverage it offers, and such requirements shall be 
     deemed to be incorporated into this subsection.''.
       (b) Conforming Amendment.--Section 2721(b)(2)(A) of such 
     Act (42 U.S.C. 300gg-21(b)(2)(A)) is amended by inserting 
     ``(other than section 2720)'' after ``requirements of such 
     subparts''.

     SEC. 1642. APPLICATION TO INDIVIDUAL HEALTH INSURANCE 
                   COVERAGE.

       Part B of title XXVII of the Public Health Service Act is 
     amended by inserting after section 2753 the following new 
     section:

     ``SEC. 2754. PATIENT PROTECTION STANDARDS.

       ``Each health insurance issuer shall comply with patient 
     protection requirements under part I of subtitle H of title I 
     of the Patient Protection and Affordable Care Act with 
     respect to individual health insurance coverage it offers, 
     and such requirements shall be deemed to be incorporated into 
     this subsection.''.

     SEC. 1643. COOPERATION BETWEEN FEDERAL AND STATE AUTHORITIES.

       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. 2795. COOPERATION BETWEEN FEDERAL AND STATE 
                   AUTHORITIES.

       ``(a) Agreement With States.--A State may enter into an 
     agreement with the Secretary for the delegation to the State 
     of some or all of the Secretary's authority under this title 
     to enforce the requirements applicable under part I of 
     subtitle H of title I of the Patient Protection and 
     Affordable Care Act with respect to health insurance coverage 
     offered by a health insurance issuer and with respect to a 
     group health plan that is a non-Federal governmental plan.
       ``(b) Delegations.--Any department, agency, or 
     instrumentality of a State to which authority is delegated 
     pursuant to an agreement entered into under this section may, 
     if authorized under State law and to the extent consistent 
     with such agreement, exercise the powers of the Secretary 
     under this title which relate to such authority.''.

PART III--AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 
                                  1974

     SEC. 1651. APPLICATION OF PATIENT PROTECTION STANDARDS TO 
                   GROUP HEALTH PLANS AND GROUP HEALTH INSURANCE 
                   COVERAGE UNDER THE EMPLOYEE RETIREMENT INCOME 
                   SECURITY ACT OF 1974.

       (a) In General.--Subpart B of part 7 of subtitle B of title 
     I of the Employee Retirement Income Security Act of 1974, as 
     amended by section 1562, is further amended by adding at the 
     end the following new section:

     ``SEC. 716. PATIENT PROTECTION STANDARDS.

       ``(a) In General.--Subject to subsection (b), a group 
     health plan (and a health insurance issuer offering group 
     health insurance coverage in connection with such a plan) 
     shall comply with the requirements of part I of subtitle H of 
     title I of the Patient Protection and Affordable Care Act (as 
     in effect as of the date of the enactment of such Act), and 
     such requirements shall be deemed to be incorporated into 
     this subsection.
       ``(b) Plan Satisfaction of Certain Requirements.--
       ``(1) Satisfaction of certain requirements through 
     insurance.--For purposes of subsection (a), insofar as a 
     group health plan provides benefits in the form of health 
     insurance coverage through a health insurance issuer, the 
     plan shall be treated as meeting the following requirements 
     of part I of subtitle H of title I of the Patient Protection 
     and Affordable Care Act with respect to such benefits and not 
     be considered as failing to meet such requirements because of 
     a failure of the issuer to meet such requirements so long as 
     the plan sponsor or its representatives did not cause such 
     failure by the issuer:
       ``(A) Section 1611 (relating to choice of health care 
     professional).
       ``(B) Section 1612 (relating to access to emergency care).
       ``(C) Section 1613 (relating to timely access to 
     specialists).
       ``(D) Section 1614 (relating to access to pediatric care).
       ``(E) Section 1615 (relating to patient access to 
     obstetrical and gynecological care).

[[Page 31820]]

       ``(F) Section 1616 (relating to continuity of care), but 
     only insofar as a replacement issuer assumes the obligation 
     for continuity of care.
       ``(2) Application to prohibitions.--Pursuant to rules of 
     the Secretary, if a health insurance issuer offers health 
     insurance coverage in connection with a group health plan and 
     takes an action in violation of section 1621 of the Patient 
     Protection and Affordable Care Act (relating to prohibition 
     of interference with certain medical communications), the 
     group health plan shall not be liable for such violation 
     unless the plan caused such violation.
       ``(3) Construction.--Nothing in this subsection shall be 
     construed to affect or modify the responsibilities of the 
     fiduciaries of a group health plan under part 4 of subtitle 
     B.
       ``(4) Treatment of substantially compliant state laws.--For 
     purposes of applying this subsection, any reference in this 
     subsection to a requirement in a section or other provision 
     in subtitle H of title I of the Patient Protection and 
     Affordable Care Act with respect to a health insurance issuer 
     is deemed to include a reference to a requirement under a 
     State law that substantially complies (as determined under 
     section 1632(c) of such Act) with the requirement in such 
     section or other provisions.
       ``(c) Conforming Regulations.--The Secretary shall issue 
     regulations to coordinate the requirements on group health 
     plans and health insurance issuers under this section with 
     the requirements imposed under the other provisions of this 
     title.''.
       (b) Satisfaction of ERISA Claims Procedure Requirement.--
     Section 503 of such Act (29 U.S.C. 1133) is amended by 
     inserting ``(a)'' after ``Sec. 503.'' and by adding at the 
     end the following new subsection:
       ``(b) In the case of a group health plan (as defined in 
     section 733) compliance with the requirements of subpart A of 
     part I of subtitle H of title I of the Patient Protection and 
     Affordable Care Act, and compliance with regulations 
     promulgated by the Secretary, in the case of a claims denial 
     shall be deemed compliance with subsection (a) with respect 
     to such claims denial.''.
       (c) Conforming Amendments.--(1) Section 732(a) of such Act 
     (29 U.S.C. 1185(a)) is amended by striking ``section 711'' 
     and inserting ``sections 711 and 716''.
       (2) The table of contents in section 1 of such Act is 
     amended by inserting after the item relating to section 715 
     the following new item:

``Sec. 716. Patient protection standards''.

       (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 title, the provisions of 
     this section (and the amendments made by this section) 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 section (or amendments) shall not be treated as a 
     termination of such collective bargaining agreement.

     SEC. 1652. EFFECTIVE DATE.

       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.
                                 ______
                                 
  SA 3220. Mr. RISCH submitted an amendment intended to be proposed to 
amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       Beginning on page 182, strike line 20 and all that follows 
     through line 4 on page 183, and insert the following:
       (3) State option to opt-out of new federal program and 
     requirements.--
       (A) In general.--In accordance with this paragraph, a State 
     may elect for the provisions of this Act to not apply within 
     such State to the extent that such provisions violate the 
     protections described in subparagraph (B).
       (B) Effect of opt-out.--In the case of a State that makes 
     an election under subparagraph (A)--
       (i) the residents of such State shall not be subject to any 
     requirement under this Act, including tax provisions or 
     penalties, that would otherwise require such residents to 
     purchase health insurance;
       (ii) the employers located in such State shall not be 
     subject to any requirement under this Act, including tax 
     provisions or penalties, that would otherwise require such 
     employers to provide health insurance to their employees or 
     make contributions relating to health insurance;
       (iii) the residents of such State shall not be prohibited 
     under this Act from receiving health care services from any 
     provider of health care services under terms and conditions 
     subject to the laws of such State and mutually acceptable to 
     the patient and the provider;
       (iv) the residents of such State shall not be prohibited 
     under this Act from entering into a contract subject to the 
     laws of such State with any group health plan, health 
     insurance issuer, or other business, for the provision of, or 
     payment to other parties for, health care services;
       (v) the eligibility of residents of such State for any 
     program operated by or funded wholly or partly by the Federal 
     Government shall not be adversely affected as a result of 
     having received services in a manner consistent with clauses 
     (iii) and (iv);
       (vi) the health care providers within such State shall not 
     be denied participation in or payment from a Federal program 
     for which they would otherwise be eligible as a result of 
     having provided services in a manner consistent with clauses 
     (iii) and (iv); and
       (vii) States that elect to opt out shall not be subject to 
     the taxes and fees enumerated in the amendments made by title 
     IX.
       (C) Process.--
       (i) In general.--A State shall be treated as making an 
     election under subparagraph (a) if--

       (I) the Governor of such State provides timely and 
     appropriate notice to the Secretary of Health and Human 
     Services notifying the Secretary that the State is making 
     such election; or
       (II) such State enacts a law making such election.

     Such notice shall be provided at least 180 days before the 
     election is to become effective.
       (ii) Revocation of election.--A State shall be treated as 
     revoking an election made by the State under subparagraph (A) 
     if--

       (I) the Governor of such State provides timely and 
     appropriate notice to the Secretary of Health and Human 
     Services of such revocation; or
       (II) such State repeals a law described in subparagraph 
     (i)(II).

     Such notice of revocation shall be provided at least 180 days 
     before the date the revocation is to become effective. As of 
     such effective date the State and the residents, employers, 
     and health insurance issuers of such State, shall be treated 
     as if the election under subparagraph (A) had not been made.
                                 ______
                                 
  SA 3221. Mr. WYDEN (for himself and Mr. Durbin) submitted an 
amendment intended to be proposed to amendment SA 2786 proposed by Mr. 
Reid (for himself, Mr. Baucus, Mr. Dodd, and Mr. Harkin) to 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; which was 
ordered to lie on the table; as follows:

       On page 1203, between lines 16 and 17, insert the 
     following:

     SEC. 4109. IMPROVING ACCESS TO CLINICAL TRIALS.

       (a) Findings.--Congress finds the following:
       (1) Advances in medicine depend on clinical trial research 
     conducted at public and private research institutions across 
     the United States.
       (2) The challenges associated with enrolling participants 
     in clinical research studies are especially difficult for 
     studies that evaluate treatments for rare diseases and 
     conditions (defined by the Orphan Drug Act as a disease or 
     condition affecting fewer than 200,000 Americans), where the 
     available number of willing and able research participants 
     may be very small.
       (3) In accordance with ethical standards established by the 
     National Institutes of Health, sponsors of clinical research 
     may provide payments to trial participants for out-of-pocket 
     costs associated with trial enrollment and for the time and 
     commitment demanded by those who participate in a study. When 
     offering compensation, clinical trial sponsors are required 
     to provide such payments to all participants.
       (4) The offer of payment for research participation may 
     pose a barrier to trial enrollment when such payments 
     threaten the eligibility of clinical trial participants for 
     Supplemental Security Income and Medicaid benefits.
       (5) With a small number of potential trial participants and 
     the possible loss of Supplemental Security Income and 
     Medicaid benefits for many who wish to participate, clinical 
     trial research for rare diseases and conditions becomes 
     exceptionally difficult and may hinder research on new 
     treatments and potential cures for these rare diseases and 
     conditions.
       (b) Exclusion for Compensation for Participation in 
     Clinical Trials for Rare Diseases or Conditions.--
       (1) Exclusion from income.--Section 1612(b) of the Social 
     Security Act (42 U.S.C. 1382a(b)) is amended--
       (A) by striking ``and'' at the end of paragraph (24);
       (B) by striking the period at the end of paragraph (25) and 
     inserting ``; and''; and

[[Page 31821]]

       (C) by adding at the end the following:
       ``(26) the first $2,000 received during a calendar year by 
     such individual (or such spouse) as compensation for 
     participation in a clinical trial involving research and 
     testing of treatments for a rare disease or condition (as 
     defined in section 5(b)(2) of the Orphan Drug Act), but only 
     if the clinical trial--
       ``(A) has been reviewed and approved by an institutional 
     review board that is established--
       ``(i) to protect the rights and welfare of human subjects 
     participating in scientific research; and
       ``(ii) in accord with the requirements under part 46 of 
     title 45, Code of Federal Regulations; and
       ``(B) meets the standards for protection of human subjects 
     as provided under part 46 of title 45, Code of Federal 
     Regulations.''.
       (2) Exclusion from resources.--Section 1613(a) of the 
     Social Security Act (42 U.S.C. 1382b(a)) is amended--
       (A) by striking ``and'' at the end of paragraph (15);
       (B) by striking the period at the end of paragraph (16) and 
     inserting ``; and''; and
       (C) by inserting after paragraph (16) the following:
       ``(17) any amount received by such individual (or such 
     spouse) which is excluded from income under section 
     1612(b)(26) (relating to compensation for participation in a 
     clinical trial involving research and testing of treatments 
     for a rare disease or condition).''.
       (3) Medicaid exclusion.--
       (A) In general.--Section 1902(e) of the Social Security Act 
     (42 U.S.C. 1396a(e)), as amended by section 2002(a), is 
     amended by adding at the end the following:
       ``(15) Exclusion of compensation for participation in a 
     clinical trial for testing of treatments for a rare disease 
     or condition.--The first $2,000 received by an individual 
     (who has attained 19 years of age) as compensation for 
     participation in a clinical trial meeting the requirements of 
     section 1612(b)(26) shall be disregarded for purposes of 
     determining the income eligibility of such individual for 
     medical assistance under the State plan or any waiver of such 
     plan.''.
       (B) Conforming amendment.--Section 1902(a)(17) of such Act 
     (42 U.S.C. 1396a(a)(17)), as amended by section 2002(b), is 
     amended by inserting ``(e)(15),'' before ``(l)(3)''.
       (4) Effective date.--The amendments made by this section 
     shall take effect on the date that is the earlier of--
       (A) the effective date of final regulations promulgated by 
     the Commissioner of Social Security to carry out this section 
     and such amendments; or
       (B) 180 days after the date of enactment of this Act.
       (5) Sunset provision.--This section and the amendments made 
     by this section are repealed on the date that is 5 years 
     after the date of the enactment of this Act.
       (c) Study and Report.--
       (1) Study.--Not later than 36 months after the effective 
     date of this section, the Comptroller General of the United 
     States shall conduct a study to evaluate the impact of this 
     section on enrollment of individuals who receive Supplemental 
     Security Income benefits under title XVI of the Social 
     Security Act (referred to in this section as ``SSI 
     beneficiaries'') in clinical trials for rare diseases or 
     conditions. Such study shall include an analysis of the 
     following:
       (A) The percentage of enrollees in clinical trials for rare 
     diseases or conditions who were SSI beneficiaries during the 
     3-year period prior to the effective date of this section as 
     compared to such percentage during the 3-year period after 
     the effective date of this section.
       (B) The range and average amount of compensation provided 
     to SSI beneficiaries who participated in clinical trials for 
     rare diseases or conditions.
       (C) The overall ability of SSI beneficiaries to participate 
     in clinical trials.
       (D) Any additional related matters that the Comptroller 
     General determines appropriate.
       (2) Report.--Not later than 12 months after completion of 
     the study conducted under paragraph (1), the Comptroller 
     General shall submit to Congress a report containing the 
     results of such study, together with recommendations for such 
     legislation and administrative action as the Comptroller 
     General determines appropriate.
                                 ______
                                 
  SA 3222. Mr. FEINGOLD submitted an amendment intended to be proposed 
to amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       On page 1525, between lines 21 and 22, insert the 
     following:
       (iv) Use of existing data and statistics and new data and 
     methodologies.--In carrying out the responsibilities 
     described in subclauses (I) through (III) of clause (iii), 
     the Institute designated under clause (i)(II) shall identify, 
     select, and incorporate existing data and statistics as well 
     as new data and methodologies that would synthesize, expand, 
     augment, improve, and modernize statistical measures to 
     provide more accurate, transparent, coherent, and 
     comprehensive assessments.
                                 ______
                                 
  SA 3223. Mr. CRAPO submitted an amendment intended to be proposed to 
amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       On page 553, between lines 14 and 15, insert the following:

     SEC. 2721. INCREASED PAYMENTS TO PRIMARY CARE PRACTITIONERS 
                   UNDER MEDICAID.

       (a) In General.--
       (1) Fee-for-service payments.--Section 1902 of the Social 
     Security Act (42 U.S.C. 1396b), as amended by section 
     2001(b)(2), 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 (hh)(1)) furnished by physicians (or for services 
     furnished by other health care professionals that would be 
     primary care services under such section if furnished by a 
     physician) at a rate not less than 80 percent of the payment 
     rate that would be applicable if the adjustment described in 
     subsection (hh)(2) were to apply to such services and 
     physicians or professionals (as the case may be) under part B 
     of title XVIII for services furnished in 2010, 90 percent of 
     such adjusted payment rate for services and physicians (or 
     professionals) furnished in 2011, or 100 percent of such 
     adjusted payment rate for services and physicians (or 
     professionals) furnished in 2012 and each subsequent year;''; 
     and
       (B) by adding at the end the following new subsection:
       ``(hh) Increased Payment for Primary Care Services.--For 
     purposes of subsection (a)(13)(C):
       ``(1) Primary care services defined.--The term `primary 
     care services' means evaluation and management services, 
     without regard to the specialty of the physician furnishing 
     the services, that are procedure codes (for services covered 
     under title XVIII) for services in the category designated 
     Evaluation and Management in the Health Care Common Procedure 
     Coding System (established by the Secretary under section 
     1848(c)(5) as of December 31, 2009, and as subsequently 
     modified by the Secretary).
       ``(2) Adjustment.--The adjustment described in this 
     paragraph is the substitution of 1.25 percent for the update 
     otherwise provided under section 1848(d)(4) for each year 
     beginning with 2010.''.
       (2) Under medicaid managed care plans.--Section 1932(f) of 
     such Act (42 U.S.C. 1396u-2(f)) is amended--
       (A) in the heading, by adding at the end the following: ``; 
     Adequacy of Payment for Primary Care Services''; and
       (B) by inserting before the period at the end the 
     following: ``and, in the case of primary care services 
     described in section 1902(a)(13)(C), consistent with the 
     minimum payment rates specified in such section (regardless 
     of the manner in which such payments are made, including in 
     the form of capitation or partial capitation)''.
       (b) Increased FMAP.--Section 1905 of such Act (42 U.S.C. 
     1396d), as amended by sections 2006 and 4107(a)(2), is 
     amended
       (1) in the first sentence of subsection (b), by striking 
     ``and'' before ``(4)'' and by inserting before the period at 
     the end the following: ``, and (5) 100 percent for periods 
     beginning with 2015 with respect to amounts described in 
     subsection (cc)''; and
       (2) by adding at the end the following new subsection:
       ``(cc) For purposes of section 1905(b)(5), the amounts 
     described in this subsection are the following:
       ``(1)(A) The portion of the amounts expended for medical 
     assistance for services described in section 1902(a)(13)(C) 
     furnished on or after January 1, 2010, that is attributable 
     to the amount by which the minimum payment rate required 
     under such section (or, by application, section 1932(f)) 
     exceeds the payment rate applicable to such services under 
     the State plan as of June 16, 2009.
       ``(B) Subparagraph (A) shall not be construed as preventing 
     the payment of Federal financial participation based on the 
     Federal medical assistance percentage for amounts in excess 
     of those specified under such subparagraph.''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to services furnished on or after January 1, 
     2010.

[[Page 31822]]


                                 ______
                                 
  SA 3224. Mr. CRAPO submitted an amendment intended to be proposed to 
amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       On page 510, between lines 9 and 10, insert the following:

     SEC. 2504. SUBMISSION OF DATA FOR PHYSICIAN ADMINISTERED 
                   DRUGS.

       (a) Extension for Implementation of Requirement for 
     Hospitals to Submit Utilization Data.--Section 1927(a)(7) of 
     the Social Security Act (42 U.S.C. 1396r-8(a)(7)) is 
     amended--
       (1) in subparagraph (A), by inserting ``in non-hospital 
     settings and on or after August 1, 2010, in hospitals'' after 
     ``January 1, 2006,'';
       (2) in subparagraph (B)(ii), by inserting ``in non-hospital 
     settings and on or after August 1, 2010, in hospitals'' after 
     ``January 1, 2008,''; and
       (3) in subparagraph (C), by inserting ``(August 1, 2010, in 
     the case of hospital information),'' after ``January 1, 
     2007,''.
       (b) Proportional Rebates for Dual Eligible Claims.--Section 
     1927(a)(7) of the Social Security Act (42 U.S.C. 1396r-
     8)(a)(7)) is amended by adding at the end the following new 
     subparagraph:
       ``(E) Temporary adjustment to rebate calculation for dual 
     eligible claims.--Only with respect to claims for rebates 
     submitted by States to manufacturers during the 2-year period 
     that begins on the date of enactment of this subparagraph, 
     for purposes of calculating the amount of rebate under 
     subsection (c) for a rebate period for a covered outpatient 
     drug for which payment is made under a State plan or waiver 
     under this title and under part B of title XVIII, the total 
     number of units reported by the State of each dosage form and 
     strength of each such drug paid for under the State plan or 
     waiver under this title during such rebate period is deemed 
     to be equal to the product of--
       ``(i) such total number of units of such drug for which 
     payment is made under the State plan or waiver under this 
     title and under part B of title XVIII; and
       ``(ii) the proportion (expressed as a percentage) that the 
     amount the State paid for each dosage form and strength of 
     such drug under the State plan or waiver under this title 
     during such rebate period bears to the amount that the State 
     would have paid for each dosage form and strength of such 
     drug under the State plan or waiver under this title during 
     such rebate period if the State were the sole payer for such 
     dosage form and strength of such drug.''.
                                 ______
                                 
  SA 3225. Mr. LeMIEUX submitted an amendment intended to be proposed 
to amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       At the appropriate place in title VI, insert the following:

     SEC. __. ESTABLISHMENT OF OFFICE OF DEPUTY SECRETARY FOR 
                   HEALTH CARE FRAUD PREVENTION IN THE DEPARTMENT 
                   OF HEALTH AND HUMAN SERVICES; APPOINTMENT AND 
                   POWERS OF DEPUTY SECRETARY.

       (a) In General.--There is hereby established in the 
     Department of Health and Human Services the Office of the 
     Deputy Secretary for Health Care Fraud Prevention (referred 
     to in this section as the ``Office'').
       (b) Duties of the Office.--The Office shall--
       (1) direct the appropriate implementation within the 
     Department of Health and Human Services of health care fraud 
     prevention and detection recommendations made by Federal 
     Government and private sector antifraud and oversight 
     entities;
       (2) routinely consult with the Office of the Inspector 
     General for the Department of Health and Human Services, the 
     Attorney General, and private sector health care antifraud 
     entities to identify emerging health care fraud issues 
     requiring immediate action by the Office;
       (3) through a fixed fee for implementation and maintenance 
     plus results-based contingency fee contract entered into with 
     an entity that has experience in designing and implementing 
     antifraud systems in the financial sector and experience and 
     knowledge of the various service delivery and reimbursement 
     models of Federal health programs, provide for the design, 
     development, and operation of a predictive model antifraud 
     system (in accordance with subsection (d)) to analyze health 
     care claims data in real-time to identify high risk claims 
     activity, develop appropriate rules, processes, and 
     procedures and investigative research approaches, in 
     coordination with the Office of the Inspector General for the 
     Department of Health and Human Services, based on the risk 
     level assigned to claims activity, and develop a 
     comprehensive antifraud database for health care activities 
     carried out or managed by Federal health agencies;
       (4) promulgate and enforce regulations relating to the 
     reporting of data claims to the health care antifraud system 
     developed under paragraph (3) by all Federal health agencies;
       (5) establish thresholds, in consultation with the Office 
     of the Inspector General of the Department of Health and 
     Human Services and the Department of Justice--
       (A) for the amount and extent of claims verified and 
     designated as fraudulent, wasteful, or abusive through the 
     fraud prevention system developed under paragraph (3) for 
     excluding providers or suppliers from participation in 
     Federal health programs; and
       (B) for the referral of claims identified through the 
     health care fraud prevention system developed under paragraph 
     (3) to law enforcement entities (such as the Office of the 
     Inspector General, Medicaid Fraud Control Units, and the 
     Department of Justice); and
       (6) share antifraud information and best practices with 
     Federal health agencies, health insurance issuers, health 
     care providers, antifraud organizations, antifraud databases, 
     and Federal, State, and local law enforcement and regulatory 
     agencies.
       (c) Deputy Secretary for Health Care Fraud Prevention.--
       (1) Establishment.--There is established within the 
     Department of Health and Human Services the position of 
     Deputy Secretary for Health Care Fraud Prevention (referred 
     to in this section as the ``Deputy Secretary''). The Deputy 
     Secretary shall serve as the head of the Office, shall act as 
     the chief health care fraud prevention and detection officer 
     of the United States, and shall consider and direct the 
     appropriate implementation of recommendations to prevent and 
     detect health care fraud, waste, and abuse activities and 
     initiatives within the Department.
       (2) Appointment.--The Deputy Secretary shall be appointed 
     by the President, by and with the advice and consent of the 
     Senate, and serve for a term of 5 years, unless removed prior 
     to the end of such term for cause by the President.
       (3) Powers.--Subject to oversight by the Secretary, the 
     Deputy Secretary shall exercise all powers necessary to carry 
     out this section, including the hiring of staff, entering 
     into contracts, and the delegation of responsibilities to any 
     employee of the Department of Health and Human Services or 
     the Office appropriately designated for such responsibility.
       (4) Duties.--
       (A) In general.--The Deputy Secretary shall--
       (i) establish and manage the operation of the predictive 
     modeling system developed under subsection (b)(3) to analyze 
     Federal health claims in real-time to identify high risk 
     claims activity and refer risky claims for appropriate 
     verification and investigative research;
       (ii) consider and order the appropriate implementation of 
     fraud prevention and detection activities, such as those 
     recommended by the Office of the Inspector General of the 
     Department of Health and Human Services, the Government 
     Accountability Office, MedPac, and private sector health care 
     antifraud entities;
       (iii) not later than 6 months after the date on which he or 
     she is initially appointed, submit to Congress an 
     implementation plan for the health care fraud prevention 
     systems under subsection (d); and
       (iv) submit annual performance reports to the Secretary and 
     Congress that, at minimum, shall provide an estimate of the 
     return on investment with respect to the system, for all 
     recommendations made to the Deputy Secretary under this 
     section, a description of whether such recommendations are 
     implemented or not implemented, and contain other relevant 
     performance metrics.
       (B) Analysis and recommendations.--The Deputy Secretary 
     shall provide required strategies and treatments for claims 
     identified as high risk (including a system of designations 
     for claims, such as ``approve'', ``decline'', ``research'', 
     and ``educate and pay'') to the Centers for Medicare & 
     Medicaid Services, other Federal and State entities 
     responsible for verifying whether claims identified as high 
     risk are payable, should be automatically denied, or require 
     further research and investigation.
       (C) Limitation.--The Deputy Secretary shall not have any 
     criminal or civil enforcement authority otherwise delegated 
     to the Office of Inspector General of the Department of 
     Health and Human Services or the Attorney General.
       (5) Regulations.--The Deputy Secretary shall promulgate and 
     enforce such rules, regulations, orders, and interpretations 
     as the Deputy Secretary determines to be necessary to carry 
     out the purposes of this section. Such authority shall be 
     exercised as provided under section 553 of title 5, United 
     States Code.
       (d) Health Care Fraud Prevention System.--

[[Page 31823]]

       (1) In general.--The fraud prevention system established 
     under subsection (b)(3) shall be designed as follows:
       (A) In general.--The fraud prevention system shall--
       (i) be holistic;
       (ii) be able to view all provider and patient activities 
     across all Federal health program payers;
       (iii) be able to integrate into the existing health care 
     claims flow with minimal effort, time, and cost;
       (iv) be modeled after systems used in the Financial 
     Services industry; and
       (v) utilize integrated real-time transaction risk scoring 
     and referral strategy capabilities to identify claims that 
     are statistically unusual.
       (B) Modularized architecture.--The fraud prevention system 
     shall be designed from an end-to-end modularized perspective 
     to allow for ease of integration into multiple points along a 
     health care claim flow (pre- or post-adjudication), which 
     shall--
       (i) utilize a single entity to host, support, manage, and 
     maintain software-based services, predictive models, and 
     solutions from a central location for the customers who 
     access the fraud prevention system;
       (ii) allow access through a secure private data connection 
     rather than the installation of software in multiple 
     information technology infrastructures (and data facilities);
       (iii) provide access to the best and latest software 
     without the need for upgrades, data security, and costly 
     installations;
       (iv) permit modifications to the software and system edits 
     in a rapid and timely manner;
       (v) ensure that all technology and decision components 
     reside within the module; and
       (vi) ensure that the third party host of the modular 
     solution is not a party, payer, or stakeholder that reports 
     claims data, accesses the results of the fraud prevention 
     systems analysis, or is otherwise required under this section 
     to verify, research, or investigate the risk of claims.
       (C) Processing, scoring, and storage.--The platform of the 
     fraud prevention system shall be a high volume, rapid, real-
     time information technology solution, which includes data 
     pooling, data storage, and scoring capabilities to quickly 
     and accurately capture and evaluate data from millions of 
     claims per day. Such platform shall be secure and have (at a 
     minimum) data centers that comply with Federal and State 
     privacy laws.
       (D) Data consortium.--The fraud prevention system shall 
     provide for the establishment of a centralized data file 
     (referred to as a ``consortium'') that accumulates data from 
     all government health insurance claims data sources. 
     Notwithstanding any other provision of law, Federal health 
     care payers shall provide to the consortium existing claims 
     data, such as Medicare's ``Common Working File'' and Medicaid 
     claims data, for the purpose of fraud and abuse prevention. 
     Such accumulated data shall be transmitted and stored in an 
     industry standard secure data environment that complies with 
     applicable Federal privacy laws for use in building medical 
     waste, fraud, and abuse prevention predictive models that 
     have a comprehensive view of provider activity across all 
     payers (and markets).
       (E) Market view.--The fraud prevention system shall ensure 
     that claims data from Federal health programs and all markets 
     flows through a central source so the waste, fraud, and abuse 
     system can look across all markets and geographies in health 
     care to identify fraud and abuse in Medicare, Medicaid, the 
     State Children's Health Program, TRICARE, and the Department 
     of Veterans Affairs, holistically. Such cross-market 
     visibility shall identify unusual provider and patient 
     behavior patterns and fraud and abuse schemes that may not be 
     identified by looking independently at one Federal payer's 
     transactions.
       (F) Behavior engine.--The fraud prevention system shall 
     ensure that the technology used provides real-time ability to 
     identify high-risk behavior patterns across markets, 
     geographies, and specialty group providers to detect waste, 
     fraud, and abuse, and to identify providers that exhibit 
     unusual behavior patterns. Behavior pattern technology that 
     provides the capability to compare a provider's current 
     behavior to their own past behavior and to compare a 
     provider's current behavior to that of other providers in the 
     same specialty group and geographic location shall be used in 
     order to provide a comprehensive waste, fraud, and abuse 
     prevention solution.
       (G) Predictive model.--The fraud prevention system shall 
     involve the implementation of a statistically sound, 
     empirically derived predictive modeling technology that is 
     designed to prevent (versus post-payment detect) waste, 
     fraud, and abuse. Such prevention system shall utilize 
     historical transaction data, from across all Federal health 
     programs and markets, to build and re-develop scoring models, 
     have the capability to incorporate external data and external 
     models from other sources into the health care predictive 
     waste, fraud, and abuse model, and provide for a feedback 
     loop to provide outcome information on verified claims so 
     future system enhancements can be developed based on previous 
     claims experience.
       (H) Change control.--The fraud prevention system platform 
     shall have the infrastructure to implement new models and 
     attributes in a test environment prior to moving into a 
     production environment. Capabilities shall be developed to 
     quickly make changes to models, attributes, or strategies to 
     react to changing patterns in waste, fraud, and abuse.
       (I) Scoring engine.--The fraud prevention system shall 
     identify high-risk claims by scoring all such claims on a 
     real-time capacity prior to payment. Such scores shall then 
     be communicated to the fraud management system provided for 
     under subparagraph (J).
       (J) Fraud management system.--The fraud prevention system 
     shall utilize a fraud management system, that contains 
     workflow management and workstation tools to provide the 
     ability to systematically present scores, reason codes, and 
     treatment actions for high-risk scored transactions. The 
     fraud prevention system shall ensure that analysts who review 
     claims have the capability to access, review, and research 
     claims efficiently, as well as decline or approve claims 
     (payments) in an automated manner. Workflow management under 
     this subparagraph shall be combined with the ability to 
     utilize principles of experimental design to compare and 
     measure prevention and detection rates between test and 
     control strategies. Such strategy testing shall allow for 
     continuous improvement and maximum effectiveness in keeping 
     up with ever changing fraud and abuse patterns. Such system 
     shall provide the capability to test different treatments or 
     actions randomly (typically through use of random digit 
     assignments).
       (K) Decision technology.--The fraud prevention system shall 
     have the capability to monitor consumer transactions in real-
     time and monitor provider behavior at different stages within 
     the transaction flow based upon provider, transaction and 
     consumer trends. The fraud prevention system shall provide 
     for the identification of provider and claims excessive usage 
     patterns and trends that differ from similar peer groups, 
     have the capability to trigger on multiple criteria, such as 
     predictive model scores or custom attributes, and be able to 
     segment transaction waste, fraud, and abuse into multiple 
     types for health care categories and business types.
       (L) Feedback loop.--The fraud prevention system shall have 
     a feedback loop where all Federal health payers provide pre-
     payment and post-payment information about the eventual 
     status of a claim designated as ``Normal'', ``Waste'', 
     ``Fraud'', ``Abuse'', or ``Education Required''. Such 
     feedback loop shall enable Federal health agencies to measure 
     the actual amount of waste, fraud, and abuse as well as the 
     savings in the system and provide the ability to retrain 
     future, enhanced models. Such feedback loop shall be an 
     industry file that contains information on previous fraud and 
     abuse claims as well as abuse perpetrated by consumers, 
     providers, and fraud rings, to be used to alert other payers, 
     as well as for subsequent fraud and abuse solution 
     development.
       (M) Tracking and reporting.--The fraud prevention system 
     shall ensure that the infrastructure exists to ascertain 
     system, strategy, and predictive model return on investment. 
     Dynamic model validation and strategy validation analysis and 
     reporting shall be made available to ensure a strategy or 
     predictive model has not degraded over time or is no longer 
     effective. Queue reporting shall be established and made 
     available for population estimates of what claims were 
     flagged, what claims received treatment, and ultimately what 
     results occurred. The capability shall exist to complete 
     tracking and reporting for prevention strategies and actions 
     residing farther upstream in the health care payment flow. 
     The fraud prevention system shall establish a reliable metric 
     to measure the dollars that are never paid due to 
     identification of fraud and abuse, as well as a capability to 
     effectively test and estimate the impact from different 
     actions and treatments utilized to detect and prevent fraud 
     and abuse for legitimate claims. Measuring results shall 
     include waste and abuse.
       (N) Operating tenet.--The fraud prevention system shall not 
     be designed to deny health care services or to negatively 
     impact prompt-pay laws because assessments are late. The 
     database shall be designed to speed up the payment process. 
     The fraud prevention system shall require the implementation 
     of constant and consistent test and control strategies by 
     stakeholders, with results shared with Federal health program 
     leadership on a quarterly basis to validate improving 
     progress in identifying and preventing waste, fraud, and 
     abuse. Under such implementation, Federal health care payers 
     shall use standard industry waste, fraud, and abuse measures 
     of success.
       (2) Coordination.--The Deputy Secretary shall coordinate 
     the operation of the fraud prevention system with the 
     Department of Justice and other related Federal fraud 
     prevention systems.
       (3) Operation.--The Deputy Secretary shall phase-in the 
     implementation of the system under this subsection beginning 
     not later than 18 months after the date of enactment of this 
     Act, through the analysis of a limited number of Federal 
     health program claims. Not later than 5 years after such

[[Page 31824]]

     date of enactment, the Deputy Secretary shall ensure that 
     such system is fully phased-in and applicable to all Federal 
     health program claims.
       (4) Non-payment of claims.--The Deputy Secretary shall 
     promulgate regulations to prohibit the payment of any health 
     care claim that has been identified as potentially 
     ``fraudulent'', ``wasteful'', or ``abusive'' until such time 
     as the claim has been verified as valid.
       (5) Application.--The system under this section shall only 
     apply to Federal health programs (all such programs), 
     including programs established after the date of enactment of 
     this Act.
       (6) Regulations.--The Deputy Secretary shall promulgate 
     regulations providing the maximum appropriate protection of 
     personal privacy consistent with carrying out the Office's 
     responsibilities under this section.
       (e) Protecting Participation in Health Care Antifraud 
     Programs.--
       (1) In general.--Notwithstanding any other provision of 
     law, no person providing information to the Secretary under 
     this section shall be held, by reason of having provided such 
     information, to have violated any criminal law, or to be 
     civilly liable under any law of the United States or of any 
     State (or political subdivision thereof) unless such 
     information is false and the person providing it knew, or had 
     reason to believe, that such information was false.
       (2) Confidentiality.--The Office shall, through the 
     promulgation of regulations, establish standards for--
       (A) the protection of confidential information submitted or 
     obtained with regard to suspected or actual health care 
     fraud;
       (B) the protection of the ability of representatives the 
     Office to testify in private civil actions concerning any 
     such information; and
       (C) the sharing by the Office of any such information 
     related to the medical antifraud programs established under 
     this section.
       (f) Protecting Legitimate Providers and Suppliers.--
       (1) Initial implementation.--Not later than 2 years after 
     the date of enactment of this Act, the Secretary shall 
     establish procedures for the implementation of fraud and 
     abuse detection methods under all Federal health programs 
     (including the programs under titles XVIII, XIX, and XXI of 
     the Social Security Act) with respect to items and services 
     furnished by providers of services and suppliers that 
     includes the following:
       (A) In the case of a new applicant to be such a provider or 
     supplier, a background check, and in the case of a supplier a 
     site visit prior to approval of participation in the program 
     and random unannounced site visits after such approval.
       (B) Not less than 5 years after the date of enactment of 
     this Act, in the case of a provider or supplier who is not a 
     new applicant, re-enrollment under the program, including a 
     new background check and, in the case of a supplier, a site-
     visit as part of the application process for such re-
     enrollment, and random unannounced site visits after such re-
     enrollment.
       (2) Requirement for participation.--In no case may a 
     provider of services or supplier who does not meet the 
     requirements under paragraph (1) participate in any Federal 
     health program.
       (3) Background checks.--The Secretary shall determine the 
     extent of the background check conducted under paragraph (1), 
     including whether--
       (A) a fingerprint check is necessary;
       (B) a background check shall be conducted with respect to 
     additional employees, board members, contractors or other 
     interested parties of the provider or supplier; and
       (C) any additional national background checks regarding 
     exclusion from participation in Federal health programs (such 
     as the program under titles XVIII, XIX, or XXI of the Social 
     Security Act), including conviction of any felony, crime that 
     involves an act of fraud or false statement, adverse actions 
     taken by State licensing boards, bankruptcies, outstanding 
     taxes, or other indications identified by the Inspector 
     General of the Department of Health and Human Services are 
     necessary.
       (4) Limitation.--No payment may be made to a provider of 
     services or supplier under any Federal health program if such 
     provider or supplier fails to obtain a satisfactory 
     background check under this subsection.
       (5) Federal health program.--In this subsection, the term 
     ``Federal health program'' means any program that provides 
     Federal payments or reimbursements to providers of health-
     related items or services, or suppliers of such items, for 
     the provision of such items or services to an individual 
     patient.
       (g) Use of Savings.--Notwithstanding any other provision on 
     law, amounts remaining at the end of a fiscal year in the 
     account for any Federal health program to which this section 
     applies that the Secretary of Health and Human Services 
     determines are remaining as a result of the fraud prevention 
     activities applied under this section shall remain in such 
     account and be used for such program for the next fiscal 
     year.
       (h) Definition.--The term ``Federal health agency'' means 
     the Department of Health and Human Services, the Department 
     of Veterans Affairs, and any Federal agency with oversight or 
     authority regarding the provision of any medical benefit, 
     item, or service for which payment may be made under a 
     Federal health care plan or contract.
                                 ______
                                 
  SA 3226. Mr. WHITEHOUSE submitted an amendment intended to be 
proposed to amendment SA 2786 proposed by Mr. Reid (for himself, Mr. 
Baucus, Mr. Dodd, and Mr. Harkin) to 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; which was ordered to lie on 
the table; as follows:

       Beginning on page 2027, strike line 20 and all that follows 
     through page 2029, line 4, and insert the following:
       (2) Amounts taken into account.--For purposes of paragraph 
     (1)--
       (A) Net premiums written.--
       (i) In general.--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 the sum of--

       (I) the net premiums written with respect to Medicaid 
     business that are taken into account during the calendar 
     year, plus
       (II) the net premiums written with respect to non-Medicaid 
     business that are taken into account during the calendar 
     year.

       (ii) Net premiums written with respect to medicaid 
     business.--

       (I) In general.--The net premiums written with respect to 
     Medicaid business that are taken into account during the 
     calendar year shall be determined in accordance with the 
     following table:


------------------------------------------------------------------------
 With respect to a covered entity's net
    premiums written with respect to      The percentage of net premiums
 Medicaid business during the calendar     written that are taken into
             year that are:                        account is:
------------------------------------------------------------------------
Not more than $100,000,000.............  0 percent
More than $100,000,000 but not more      25 percent
 than $150,000,000.
More than $150,000,000 but not more      50 percent
 than $200,000,000.
More than $200,000,000.................  100 percent.
------------------------------------------------------------------------

       (II) Medicaid business.--For purposes of this section, net 
     premiums written with respect to Medicaid business means, 
     with respect to any covered entity, that portion of the net 
     premiums written with respect to health insurance for United 
     States health risks which are written with respect to 
     individuals who are eligible for medical assistance under, 
     and enrolled in, a State plan under title XIX of the Social 
     Security Act or a waiver of such plan. Such amounts shall be 
     reported separately by each covered entity in the report 
     required under subsection (g).

       (iii) Net premiums written with respect to non-medicaid 
     business.--

       (I) In general.--The net premiums written with respect to 
     non-Medicaid business that are taken into account during the 
     calendar year shall be determined in accordance with the 
     following table:


------------------------------------------------------------------------
 With respect to a covered entity's net
 premiums written with respect to non-    The percentage of net premiums
 Medicaid business 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 than  50 percent
 $50,000,000.

[[Page 31825]]

 
More than $50,000,000..................  100 percent.
------------------------------------------------------------------------

       (II) Non-medicaid business.--For purpose of this section, 
     the net premiums written with respect to non-Medicaid 
     business means, with respect to any covered entity, the total 
     amount of net premiums written with respect to health 
     insurance for United States health risks less the net 
     premiums written with respect to Medicaid business.

       (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 than   50 percent
 $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) Performance Adjustment to Annual Fee.--
       (1) In general.--The Secretary shall--
       (A) in the case of a penalized covered entity, increase the 
     fee determined under subsection (b) for a calendar year as 
     provided in paragraph (3), and
       (B) in the case of any other covered entity, reduce the fee 
     determined under subsection (b) for a calendar year as 
     provided in paragraph (4).
       (2) Penalized covered entity described.--
       (A) In general.--For purposes of this paragraph, the term 
     ``penalized covered entity'' means a covered entity that the 
     Secretary determines has failed to meet the key performance 
     thresholds (established under subparagraph (B)) for the 
     calendar year involved.
       (B) Key performance thresholds.--The key performance 
     thresholds established under this subparagraph are as 
     follows:
       (i) Medical loss ratio threshold.--The covered entity has a 
     medical loss ratio, as reported under section 2718(a)(1) of 
     the Public Health Service Act, of not less than 85 percent. 
     The Secretary, in consultation with the Secretary of Health 
     and Human Services may increase, but not decrease, such 
     percentage by regulation.
       (ii) Maximum financial reserve threshold.--

       (I) In general.--The covered entity has a financial reserve 
     which is not greater than the amount established under 
     regulations by the Secretary, in consultation with the 
     Secretary of Health and Human Services. The Secretary may 
     establish different thresholds for different categories of 
     covered entity under this section. The Secretary, in 
     consultation with the National Association of Insurance 
     Commissioners, shall establish a uniform methodology for 
     reporting financial reserve levels and determining maximum 
     financial reserve thresholds under this subparagraph.
       (II) Reports.--Each covered entity shall annually submit a 
     report (in a manner to be established by the Secretary 
     through regulation) to the Secretary and the Secretary of 
     Health and Human Services containing such information about 
     the financial reserves of the entity as the Secretary may 
     require. The rules of subsection (g)(2) shall apply to the 
     information required to be reported under this subclause.

       (3) Amount of fee increase.--
       (A) In general.--In the case of a penalized covered entity, 
     the fee determined under subsection (b) for the calendar year 
     shall be increased by the penalty amount.
       (B) Penalty amount.--
       (i) In general.--The penalty amount shall be the product 
     of--

       (I) the amount determined under subsection (b), and
       (II) the sum of the amounts determined under subparagraphs 
     (C) and (D).

       (ii) Limitation.--The penalty amount shall not exceed 20 
     percent of the amount determined under subsection (b).
       (C) Medical loss ratio component.--The amount determined 
     under this subparagraph is the amount equal to the excess 
     of--
       (i) the medical loss ratio threshold established under 
     paragraph (2)(A), over
       (ii) the medical loss ratio (expressed in decimal form) of 
     the penalized covered entity.
       (D) Financial reserve component.--The amount determined 
     under this subparagraph is the amount equal to the ratio of--
       (i) the excess of--

       (I) the financial reserves of the penalized covered entity, 
     over
       (II) the maximum financial reserve threshold established 
     under paragraph (2)(B)(ii), to

       (ii) such maximum financial reserve threshold.
       (4) Reduction in fee.--
       (A) In general.--
       (i) Amount of reduction.--In the case of any covered entity 
     that is not a penalized covered entity, the fee determined 
     under subsection (b) for the calendar year shall be reduced 
     by an amount equal to the product of--

       (I) the sum of all penalty amounts assessed in the calendar 
     year under paragraph (3), and
       (II) the fee redistribution ratio.

       (ii) Limitation.--The reduction under this paragraph shall 
     not exceed 20 percent of the amount determined under 
     subsection (b).
       (B) Fee distribution ratio.--For purposes of this 
     paragraph, the fee redistribution ratio is the ratio of--
       (i) the weighted net written premium amount of the covered 
     entity, to
       (ii) the aggregate of the weighted net written premium 
     amount of all covered entities.
       (C) Weighted net written premium amount.--For purposes of 
     this paragraph, the weighted net written premium amount with 
     respect to any covered entity is the amount described in 
     subsection (b)(1)(A)(i) with respect to such covered entity, 
     increased by the product of--
       (i) such amount, and
       (ii) the product of 0.05 and the sum of the amounts 
     determined under subparagraphs (D) and (E).
       (D) Medical loss ratio component.--The amount determined 
     under this subparagraph is the amount equal to the excess 
     of--
       (i) the medical loss ratio (expressed as a percentage) of 
     the covered entity, over
       (ii) the medical loss ratio threshold established under 
     paragraph (2)(A).
       (E) Financial reserve component.--The amount determined 
     under this subparagraph is the amount equal to the ratio of--
       (i) the excess of--

       (I) the maximum financial reserve threshold established 
     under paragraph (2)(B)(ii), over
       (II) the financial reserves of the covered entity, to

       (ii) such maximum financial reserve threshold.
                                 ______
                                 
  SA 3227. Mr. CARDIN submitted an amendment intended to be proposed to 
amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       On page 731, strike line 17 and all that follows through 
     line 10 on page 732 and insert the following:
       ``(xix) Using commonly available and inexpensive 
     technologies, including wireless and Internet-based tools, 
     that have a demonstrated ability to improve patient outcomes 
     or reduce health care costs, to simplify the complex 
     management and treatment of chronic diseases for patients and 
     health care providers.
       ``(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

[[Page 31826]]

     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, wireless and Internet-based 
     tools,''.
                                 ______
                                 
  SA 3228. Ms. LANDRIEU (for herself, Mr. Warner, and Mr. Akaka) 
submitted an amendment intended to be proposed to amendment SA 2786 
proposed by Mr. Reid (for himself, Mr. Baucus, Mr. Dodd, and Mr. 
Harkin) to 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; which was ordered to lie on the table; as follows:

       On page 396, between lines 8 and 9, insert the following:

     SEC. 1563. PROVISIONS RELATED TO VISION BENEFITS.

       (a) Exemption From Comprehensive Coverage Requirement.--
     Section 2707 of the Public Health Service Act, as added by 
     section 1201, is amended by adding at the end the following:
       ``(e) Vision Only.--This section shall not apply to a plan 
     described in section 1311(d)(2)(B)(iii) of the Patient 
     Protection and Affordable Care Act.''.
       (b) Essential Health Benefits.--Section 1302 of this Act is 
     amended--
       (1) in subsection (b)(4)--
       (A) by redesignating subparagraphs (G) and (H) as 
     subparagraphs (H) and (I), respectively;
       (B) by inserting after subparagraph (F) the following:
       ``(G) provide that if a plan described in section 
     1311(d)(2)(B)(iii) (relating to stand-alone vision 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
       (C) in subparagraph (I), as so redesignated, by striking 
     ``(G)'' and inserting ``(H)''; and
       (2) by striking ``paragraph (4)(H)'' each place such term 
     appears and inserting ``paragraph (4)(I)''.
       (c) Offering of Coverage.--Section 1311(d)(2)(B) of this 
     Act is amended by adding at the end the following:
       ``(iii) Offering of stand-alone vision benefits.--Each 
     Exchange within a State shall allow an issuer of a plan that 
     only provides limited scope vision 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 vision benefits meeting the 
     requirements of section 1302(b)(1)(J)).''.
       (d) Refundable Credit.--Section 36B(b) of the Internal 
     Revenue Code of 1986, as added by section 1401, is amended by 
     adding at the end the following:
       ``(F) Special rule for pediatric vision 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)(iii) 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 vision 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.''.
       (e) Reduced Cost-Sharing.--Section 1402(c) of this Act is 
     amended by adding at the end the following:
       ``(6) Special rule for pediatric vision plans.--If an 
     individual enrolls in both a qualified health plan and a plan 
     described in section 1311(d)(2)(B)(iii) 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 vision benefits which are included in 
     the essential health benefits required to be provided by a 
     qualified health plan under section 1302(b)(1)(J).''.
                                 ______
                                 
  SA 3229. Mr. CRAPO submitted an amendment intended to be proposed to 
amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       Beginning on page 510, strike line 10 and all that follows 
     through page 515, line 11.
                                 ______
                                 
  SA 3230. Mr. CRAPO submitted an amendment intended to be proposed to 
amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       On page 436, between lines 14 and 15, insert the following:

     SEC. 2008. NON-APPLICATION OF MEDICAID EXPANSION MANDATES.

       Notwithstanding any other provision of this Act (or an 
     amendment made by this Act), with respect to a State, any 
     provision of this Act or amendment made by this Act that 
     imposes on the State an expansion of coverage under the 
     Medicaid program shall not apply to the State if such 
     expansion would result in the State incurring costs for 
     providing medical assistance to individuals enrolled under 
     the State Medicaid program that are greater than the costs 
     the State would have incurred if this Act and such amendments 
     had not been enacted.
                                 ______
                                 
  SA 3231. Mr. CRAPO submitted an amendment intended to be proposed to 
amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       On page 828, between lines 3 and 4, insert the following:

     SEC. 3130. ENHANCED FMAP TO PROVIDE INCREASED PAYMENTS FOR 
                   PHYSICIANS' SERVICES AND INPATIENT HOSPITAL 
                   SERVICES FURNISHED IN RURAL AREAS.

       Notwithstanding any other provision of law, if at any time 
     after January 1, 2014, a State increases, by not less than 
     the rate applicable under the Medicare program, the payment 
     rates under its State Medicaid program for medical assistance 
     consisting of physician services or inpatient hospital 
     services that are furnished in rural areas (as defined in 
     section 1886(d)(2)(D) of the Social Security Act (42 U.S.C. 
     1395ww(d)(2)(D))) of the State, the Federal medical 
     assistance percentage otherwise applicable to such 
     expenditures shall be increased by an amount equal to 100 
     percent of the increase in such rates from the rates 
     applicable under the State Medicaid program for fiscal year 
     2009.
                                 ______
                                 
  SA 3232. Mr. BYRD submitted an amendment intended to be proposed to 
amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       On page 1356, strike line 3 and insert the following:
       ``(2) Priority.--In awarding grants under paragraph (1), 
     the Secretary shall give priority to eligible entities that 
     are located in States that have high rates of dental health 
     care disparities.
                                 ______
                                 
  SA 3233. Mr. BYRD submitted an amendment intended to be proposed to 
amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       On page 94, between lines 3 and 4, insert the following:
       ``(4) Selection.--In selecting States to participate in the 
     demonstration project under this subsection, the Secretary 
     shall give priority to States that have populations with high 
     rates of--
       ``(A) chronic diseases, with particular emphasis on 
     inclusion of States that have populations with high rates of 
     diabetes, hypertension, and cardiovascular disease;
       ``(B) smoking and use of tobacco products; or
       ``(C) obesity.''.
                                 ______
                                 
  SA 3234. Mr. CASEY submitted an amendment intended to be proposed to

[[Page 31827]]

amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       On page 764, between lines 2 and 3, insert the following:
       ``(i) 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 section1886(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).''.
                                 ______
                                 
  SA 3235. Mr. CASEY (for himself and Mr. Specter) submitted an 
amendment intended to be proposed to amendment SA 2786 proposed by Mr. 
Reid (for himself, Mr. Baucus, Mr. Dodd, and Mr. Harkin) to 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; which was 
ordered to lie on the table; as follows:

       On page 923, between lines 7 and 8, insert the following:

     SEC. 3211. IMPROVEMENTS TO TRANSITIONAL EXTRA BENEFITS UNDER 
                   MEDICARE ADVANTAGE.

       Section 1853(p) of the Social Security Act, as added by 
     section 3201, is amended--
       (1) in paragraph (3)--
       (A) by redesignating subparagraph (C) as subparagraph (D);
       (B) in subparagraph (D), as so redesignated, by striking 
     ``(A) or (B)'' and inserting ``(A), (B), or (C)'';
       (C) by inserting after subparagraph (B) the following new 
     subparagraph:
       ``(C) A county--
       ``(i) where the percentage of Medicare Advantage eligible 
     beneficiaries in the county who are enrolled in an MA plan 
     for the year is greater than 45 percent (as determined by the 
     Secretary); and
       ``(ii) that is located in a State in which the percentage 
     of residents over the age of 65 is greater than 14 percent 
     (as determined by the Secretary).'';
       (D) by inserting after subparagraph (C) the following flush 
     sentence:

     ``Such term shall not include any MA local area identified 
     under subsection (o)(1).''; and
       (2) in paragraph (5), by striking ``$5,000,000,000'' and 
     inserting ``$7,000,000,000''.
                                 ______
                                 
  SA 3236. Mr. KOHL submitted an amendment intended to be proposed to 
amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       On page 731, between lines 16 and 17, insert the following:
       ``(xix) Implementing the lean methodology through a network 
     of provider systems across the country in varying geographic 
     areas and across sites of care that offer a patient-centered 
     approach to improving quality, reducing medical errors, and 
     enhancing value to patients.
                                 ______
                                 
  SA 3237. Mr. BURRIS submitted an amendment intended to be proposed to 
amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       At the appropriate place in title III, insert the 
     following:

     SEC. __. PERMITTING PHYSICAL THERAPY TO BE FURNISHED UNDER 
                   THE MEDICARE PROGRAM UNDER THE CARE OF A 
                   DENTIST.

       (a) In General.--Section 1861(p)(1) of the Social Security 
     Act (42 U.S.C. 1395x(p)(1)) is amended by inserting ``(2),'' 
     after ``(1),''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to items and services furnished on or after the 
     date of the enactment of this Act.
                                 ______
                                 
  SA 3238. Mr. ROCKEFELLER (for himself, Mr. Kohl, Mr. Carper, and Mr. 
Warner) submitted an amendment intended to be proposed to amendment SA 
2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. Dodd, and Mr. 
Harkin) to 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; which was ordered to lie on the table; as follows:

       On page 2074, after line 25, add the following:
               TITLE X--COVERAGE OF ADVANCE CARE PLANNING

     SEC. 10001. MEDICARE, MEDICAID, AND CHIP COVERAGE.

       (a) Medicare.--
       (1) In general.--Section 1861 of the Social Security Act 
     (42 U.S.C. 1395x), as amended by section 4103, is amended--
       (A) in subsection (s)(2)--
       (i) by striking ``and'' at the end of subparagraph (EE);
       (ii) by adding ``and'' at the end of subparagraph (FF); and
       (iii) by adding at the end the following new subparagraph:
       ``(GG) voluntary advance care planning consultation (as 
     defined in subsection (iii)(1));''; and
       (B) by adding at the end the following new subsection:

             ``Voluntary Advance Care Planning Consultation

       ``(iii)(1) Subject to paragraphs (3) and (4), the term 
     `voluntary advance care planning consultation' means an 
     optional consultation between the individual and a 
     practitioner described in paragraph (2) regarding advance 
     care planning, if, subject to subparagraphs (A) and (B) of 
     paragraph (3), the individual involved has not had such a 
     consultation within the last 5 years. Such consultation shall 
     include the following:
       ``(A) An explanation by the practitioner of advance care 
     planning, including key questions and considerations, 
     important steps, and suggested people to talk to.
       ``(B) An explanation by the practitioner of advance 
     directives, including living wills and durable powers of 
     attorney, and their uses.
       ``(C) An explanation by the practitioner of the role and 
     responsibilities of a health care proxy.
       ``(D) The provision by the practitioner of a list of 
     national and State-specific resources to assist consumers and 
     their families with advance care planning, including the 
     national toll-free hotline, the advance care planning 
     clearinghouses, and State legal service organizations 
     (including those funded through the Older Americans Act).
       ``(E) An explanation by the practitioner of the continuum 
     of end-of-life services and supports available, including 
     palliative care and hospice, and benefits for such services 
     and supports that are available under this title.
       ``(F)(i) Subject to clause (ii), an explanation of orders 
     regarding life sustaining treatment or similar orders, which 
     shall include--
       ``(I) the reasons why the development of such an order is 
     beneficial to the individual and the individual's family and 
     the reasons why such an order should be updated periodically 
     as the health of the individual changes;
       ``(II) the information needed for an individual or legal 
     surrogate to make informed decisions regarding the completion 
     of such an order; and
       ``(III) the identification of resources that an individual 
     may use to determine the requirements of the State in which 
     such individual resides so that the treatment wishes of that 
     individual will be carried out if the individual is unable to 
     communicate those wishes, including requirements regarding 
     the designation of a surrogate decisionmaker (also known as a 
     health care proxy).
       ``(ii) The Secretary may limit the requirement for 
     explanations under clause (i) to consultations furnished in 
     States, localities, or other geographic areas in which orders 
     described in such clause have been widely adopted.
       ``(2) A practitioner described in this paragraph is--
       ``(A) a physician (as defined in subsection (r)(1)); and

[[Page 31828]]

       ``(B) a nurse practitioner or physician's assistant who has 
     the authority under State law to sign orders for life 
     sustaining treatments.
       ``(3)(A) An initial preventive physical examination under 
     subsection (ww), including any related discussion during such 
     examination, shall not be considered an advance care planning 
     consultation for purposes of applying the 5-year limitation 
     under paragraph (1).
       ``(B) A voluntary advance care planning consultation with 
     respect to an individual shall be conducted more frequently 
     than provided under paragraph (1) if there is a significant 
     change in the health condition of the individual, including 
     diagnosis of a chronic, progressive, life-limiting disease, a 
     life-threatening or terminal diagnosis or life-threatening 
     injury, or upon admission to a skilled nursing facility, a 
     long-term care facility (as defined by the Secretary), or a 
     hospice program.
       ``(4) A consultation under this subsection may include the 
     formulation of an order regarding life sustaining treatment 
     or a similar order.
       ``(5)(A) For purposes of this section, the term `order 
     regarding life sustaining treatment' means, with respect to 
     an individual, an actionable medical order relating to the 
     treatment of that individual that--
       ``(i) is signed and dated by a physician (as defined in 
     subsection (r)(1)) or another health care professional (as 
     specified by the Secretary and who is acting within the scope 
     of the professional's authority under State law in signing 
     such an order) and is in a form that permits it to stay with 
     the patient and be followed by health care professionals and 
     providers across the continuum of care, including home care, 
     hospice, long-term care, community and assisted living 
     residences, skilled nursing facilities, inpatient 
     rehabilitation facilities, hospitals, and emergency medical 
     services;
       ``(ii) effectively communicates the individual's 
     preferences regarding life sustaining treatment, including an 
     indication of the treatment and care desired by the 
     individual;
       ``(iii) is uniquely identifiable and standardized within a 
     given locality, region, or State (as identified by the 
     Secretary);
       ``(iv) is portable across care settings; and
       ``(v) may incorporate any advance directive (as defined in 
     section 1866(f)(3)) if executed by the individual.
       ``(B) The level of treatment indicated under subparagraph 
     (A)(ii) may range from an indication for full treatment to an 
     indication to limit some or all or specified interventions. 
     Such indicated levels of treatment may include indications 
     respecting, among other items--
       ``(i) the intensity of medical intervention if the patient 
     is pulseless, apneic, or has serious cardiac or pulmonary 
     problems;
       ``(ii) the individual's desire regarding transfer to a 
     hospital or remaining at the current care setting;
       ``(iii) the use of antibiotics; and
       ``(iv) the use of artificially administered nutrition and 
     hydration.''.
       (2) Payment.--Section 1848(j)(3) of the Social Security Act 
     (42 U.S.C. 1395w-4(j)(3)), as amended by section 4103(c)(2), 
     is amended by inserting ``(2)(GG),'' after ``(2)(FF) 
     (including administration of the health risk assessment),''.
       (3) Frequency limitation.--Section 1862(a) of the Social 
     Security Act (42 U.S.C. 1395y(a)(1)), as amended by section 
     4103(d), is amended--
       (A) in paragraph (1)--
       (i) in subparagraph (O), by striking ``and'' at the end;
       (ii) in subparagraph (P) by striking the semicolon at the 
     end and inserting ``, and''; and
       (iii) by adding at the end the following new subparagraph:
       ``(Q) in the case of advance care planning consultations 
     (as defined in section 1861(iii)(1)), which are performed 
     more frequently than is covered under such section;''; and
       (B) in paragraph (7), by striking ``or (P)'' and inserting 
     ``(P), or (Q)''.
       (4) Effective date.--The amendments made by this subsection 
     shall apply to consultations furnished on or after January 1, 
     2011 .
       (b) Medicaid.--
       (1) Mandatory benefit.--Section 1902(a)(10)(A) of the 
     Social Security Act (42 U.S.C. 1396a(a)(10)(A)), as amended 
     by section 2301(b), is amended in the matter preceding clause 
     (i) by striking ``and (28)'' and inserting ``, (28), and 
     (29)''.
       (2) Medical assistance.--Section 1905 of such Act (42 
     U.S.C. 1396d), as amended by sections 2001(a)(3), 2006, and 
     2301(a)(1), is amended--
       (A) in subsection (a)--
       (i) in paragraph (28), by striking ``and'' at the end;
       (ii) by redesignating paragraph (29) as paragraph (30); and
       (iii) by inserting after paragraph (28) the following new 
     paragraph:
       ``(29) advance care planning consultations (as defined in 
     subsection (z));''; and
       (B) by inserting after subsection (y) the following new 
     subsection:
       ``(z)(1) For purposes of subsection (a)(28), the term 
     `voluntary advance care planning consultation' means an 
     optional consultation between the individual and a 
     practitioner described in paragraph (2) regarding advance 
     care planning, if, subject to paragraph (3), the individual 
     involved has not had such a consultation within the last 5 
     years. Such consultation shall include the following:
       ``(A) An explanation by the practitioner of advance care 
     planning, including key questions and considerations, 
     important steps, and suggested people to talk to.
       ``(B) An explanation by the practitioner of advance 
     directives, including living wills and durable powers of 
     attorney, and their uses.
       ``(C) An explanation by the practitioner of the role and 
     responsibilities of a health care proxy.
       ``(D) The provision by the practitioner of a list of 
     national and State-specific resources to assist consumers and 
     their families with advance care planning, including the 
     national toll-free hotline, the advance care planning 
     clearinghouses, and State legal service organizations 
     (including those funded through the Older Americans Act).
       ``(E) An explanation by the practitioner of the continuum 
     of end-of-life services and supports available, including 
     palliative care and hospice, and benefits for such services 
     and supports that are available under this title.
       ``(F)(i) Subject to clause (ii), an explanation of orders 
     for life sustaining treatments or similar orders, which shall 
     include--
       ``(I) the reasons why the development of such an order is 
     beneficial to the individual and the individual's family and 
     the reasons why such an order should be updated periodically 
     as the health of the individual changes;
       ``(II) the information needed for an individual or legal 
     surrogate to make informed decisions regarding the completion 
     of such an order; and
       ``(III) the identification of resources that an individual 
     may use to determine the requirements of the State in which 
     such individual resides so that the treatment wishes of that 
     individual will be carried out if the individual is unable to 
     communicate those wishes, including requirements regarding 
     the designation of a surrogate decisionmaker (also known as a 
     health care proxy).
       ``(ii) The Secretary may limit the requirement for 
     explanations under clause (i) to consultations furnished in 
     States, localities, or other geographic areas in which orders 
     described in such clause have been widely adopted.
       ``(2) A practitioner described in this paragraph is--
       ``(A) a physician (as defined in section 1861(r)(1)); and
       ``(B) a nurse practitioner or physician's assistant who has 
     the authority under State law to sign orders for life 
     sustaining treatments.
       ``(3) A voluntary advance care planning consultation with 
     respect to an individual shall be conducted more frequently 
     than provided under paragraph (1) if there is a significant 
     change in the health condition of the individual including 
     diagnosis of a chronic, progressive, life-limiting disease, a 
     life-threatening or terminal diagnosis or life-threatening 
     injury, or upon admission to a nursing facility, a long-term 
     care facility (as defined by the Secretary), or a hospice 
     program.
       ``(4) A consultation under this subsection may include the 
     formulation of an order regarding life sustaining treatment 
     or a similar order.
       ``(5) For purposes of this subsection, the term `orders 
     regarding life sustaining treatment' has the meaning given 
     that term in section 1861(iii)(5).''.
       (c) CHIP.--
       (1) Child health assistance.--Section 2110(a) of the Social 
     Security Act (42 U.S.C. 1397jj) is amended--
       (A) by redesignating paragraph (28) as paragraph (29); and
       (B) by inserting after paragraph (27), the following:
       ``(28) Voluntary advance care planning consultations (as 
     defined in section 1905(z)).''.
       (2) Mandatory coverage.--
       (A) In general.--Section 2103 of such Act (42 U.S.C. 
     1397cc), is amended--
       (i) in subsection (a), in the matter preceding paragraph 
     (1), by striking ``and (7)'' and inserting ``(7), and (9)''; 
     and
       (ii) in subsection (c), by adding at the end the following:
       ``(9) End-of-life care.--The child health assistance 
     provided to a targeted low-income child shall include 
     coverage of voluntary advance care planning consultations (as 
     defined in section 1905(z) and at the same payment rate as 
     the rate that would apply to such a consultation under the 
     State plan under title XIX).''.
       (B) Conforming amendment.--Section 2102(a)(7)(B) of such 
     Act (42 U.S.C. 1397bb(a)(7)(B)) is amended by striking 
     ``section 2103(c)(5)'' and inserting ``paragraphs (5) and (9) 
     of section 2103(c)''.
       (d) Definition of Advance Directive Under Medicare, 
     Medicaid, and CHIP.--
       (1) Medicare.--Section 1866(f)(3) of the Social Security 
     Act (42 U.S.C. 1395cc(f)(3)) is amended by striking ``means'' 
     and all that follows through the period and inserting ``means 
     a living will, medical directive, health care power of 
     attorney, durable power

[[Page 31829]]

     of attorney, or other written statement by a competent 
     individual that is recognized under State law and indicates 
     the individual's wishes regarding medical treatment in the 
     event of future incompetence. Such term includes an advance 
     health care directive and a health care directive recognized 
     under State law.''.
       (2) Medicaid and chip.--Section 1902(w)(4) of such Act (42 
     U.S.C. 1396a(w)(4)) is amended by striking ``means'' and all 
     that follows through the period and inserting ``means a 
     living will, medical directive, health care power of 
     attorney, durable power of attorney, or other written 
     statement by a competent individual that is recognized under 
     State law and indicates the individual's wishes regarding 
     medical treatment in the event of future incompetence. Such 
     term includes an advance health care directive and a health 
     care directive recognized under State law.''.
       (e) Rule of Construction.--A voluntary advance care 
     planning consultation described under any provision of this 
     section or amendment made by this section shall be provided 
     solely at the option of the applicable individual. Nothing in 
     this section shall be construed to--
       (1) require an individual to complete an advance directive, 
     an order for life-sustaining treatment, or other advance care 
     planning document;
       (2) require an individual to consent to restrictions on the 
     amount, duration, or scope of medical benefits that such 
     individual is entitled to receive through any program under 
     titles XVIII, XIX, or XXI of the Social Security Act; or
       (3) encourage or promote suicide or assisted suicide.
       (f) Effective Date.--The amendments made by this section 
     take effect January 1, 2010.

     SEC. 10002. DISSEMINATION OF ADVANCE CARE PLANNING 
                   INFORMATION.

       (a) In General.--A health insurance issuer offering a 
     qualified health plan--
       (1) shall provide for the dissemination of information 
     related to end-of-life planning to individuals seeking 
     enrollment in qualified health plans offered through the 
     Exchange;
       (2) shall present such individuals with--
       (A) the option to establish advanced directives and 
     physician's orders for life sustaining treatment according to 
     the laws of the State in which the individual resides; and
       (B) information related to other planning tools; and
       (3) shall not promote suicide, assisted suicide, 
     euthanasia, or mercy killing.

     The information presented under paragraph (2) shall not 
     presume the withdrawal of treatment and shall include end-of-
     life planning information that includes options to maintain 
     all or most medical interventions.
       (b) Construction.--Nothing in this section shall be 
     construed--
       (1) to require an individual to complete an advanced 
     directive or a physician's order for life sustaining 
     treatment or other end-of-life planning document;
       (2) to require an individual to consent to restrictions on 
     the amount, duration, or scope of medical benefits otherwise 
     covered under a qualified health plan; or
       (3) to promote suicide, assisted suicide, euthanasia, or 
     mercy killing.
       (c) Advanced Directive Defined.--In this section, the term 
     ``advanced directive'' includes a living will, a comfort care 
     order, or a durable power of attorney for health care.
       (d) Prohibition on the Promotion of Assisted Suicide.--
       (1) In general.--Subject to paragraph (3), information 
     provided to meet the requirements of subsection (a)(2) shall 
     not include advanced directives or other planning tools that 
     list or describe as an option suicide, assisted suicide, 
     euthanasia, or mercy killing, regardless of legality.
       (2) Construction.--Nothing in paragraph (1) shall be 
     construed to apply to or affect any option to--
       (A) withhold or withdraw of medical treatment or medical 
     care;
       (B) withhold or withdraw of nutrition or hydration; and
       (C) provide palliative or hospice care or use an item, 
     good, benefit, or service furnished for the purpose of 
     alleviating pain or discomfort, even if such use may increase 
     the risk of death, so long as such item, good, benefit, or 
     service is not also furnished for the purpose of causing, or 
     the purpose of assisting in causing, death, for any reason.
       (3) No preemption of state law.--Nothing in this section 
     shall be construed to preempt or otherwise have any effect on 
     State laws regarding advance care planning, palliative care, 
     or end-of-life decision-making.
                                 ______
                                 
  SA 3239. Mr. ROCKEFELLER (for himself, Ms. Collins, and Mr. Kohl) 
submitted an amendment intended to be proposed to amendment SA 2786 
proposed by Mr. Reid (for himself, Mr. Baucus, Mr. Dodd, and Mr. 
Harkin) to 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; which was ordered to lie on the table; as follows:

       On page 2074, after line 25, add the following:

         TITLE X--ADVANCE CARE PLANNING AND COMPASSIONATE CARE

     SECTION 10001. SHORT TITLE.

       This title may be cited as the ``Advance Planning and 
     Compassionate Care Act of 2009''.

     SEC. 10002. DEFINITIONS.

       In this title:
       (1) Advance care planning.--The term ``advance care 
     planning'' means the process of--
       (A) determining an individual's priorities, values and 
     goals for care in the future when the individual is no longer 
     able to express his or her wishes;
       (B) engaging family members, health care proxies, and 
     health care providers in an ongoing dialogue about--
       (i) the individual's wishes for care;
       (ii) what the future may hold for people with serious 
     illnesses or injuries;
       (iii) how individuals, their health care proxies, and 
     family members want their beliefs and preferences to guide 
     care decisions; and
       (iv) the steps that individuals and family members can take 
     regarding, and the resources available to help with, 
     finances, family matters, spiritual questions, and other 
     issues that impact seriously ill or dying patients and their 
     families; and
       (C) executing and updating advance directives and 
     appointing a health care proxy.
       (2) Advance directive.--The term ``advance directive'' 
     means a living will, medical directive, health care power of 
     attorney, durable power of attorney, or other written 
     statement by a competent individual that is recognized under 
     State law and indicates the individual's wishes regarding 
     medical treatment in the event of future incompetence. Such 
     term includes an advance health care directive and a health 
     care directive recognized under State law.
       (3) CHIP.--The term ``CHIP'' means the program established 
     under title XXI of the Social Security Act (42 U.S.C. 1397aa 
     et seq.).
       (4) End-of-life-care.--The term ``end-of-life care'' means 
     all aspects of care of a patient with a potentially fatal 
     condition, and includes care that is focused on specific 
     preparations for an impending death.
       (5) Health care power of attorney.--The term ``health care 
     power of attorney'' means a legal document that identifies a 
     health care proxy or decisionmaker for a patient who has the 
     authority to act on the patient's behalf when the patient is 
     unable to communicate his or her wishes for medical care on 
     matters that the patient specifies when he or she is 
     competent. Such term includes a durable power of attorney 
     that relates to medical care.
       (6) Living will.--The term ``living will'' means a legal 
     document--
       (A) used to specify the type of medical care (including any 
     type of medical treatment, including life-sustaining 
     procedures if that person becomes permanently unconscious or 
     is otherwise dying) that an individual wants provided or 
     withheld in the event the individual cannot speak for himself 
     or herself and cannot express his or her wishes; and
       (B) that requires a physician to honor the provisions of 
     upon receipt or to transfer the care of the individual 
     covered by the document to another physician that will honor 
     such provisions.
       (7) Medicaid.--The term ``Medicaid'' means the program 
     established under title XIX of the Social Security Act (42 
     U.S.C. 1396 et seq.).
       (8) Medicare.--The term ``Medicare'' means the program 
     established under title XVIII of the Social Security Act (42 
     U.S.C. 1395 et seq.).
       (9) Orders for life-sustaining treatment.--The term 
     ``orders for life-sustaining treatment'' means a process for 
     focusing a patients' values, goals, and preferences on 
     current medical circumstances and to translate such into 
     visible and portable medical orders applicable across care 
     settings, including home, long-term care, emergency medical 
     services, and hospitals.
       (10) Palliative care.--The term ``palliative care'' means 
     interdisciplinary care for individuals with a life-
     threatening illness or injury relating to pain and symptom 
     management and psychological, social, and spiritual needs and 
     that seeks to improve the quality of life for the individual 
     and the individual's family.
       (11) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.

              Subtitle A--Consumer and Provider Education

                       PART I--CONSUMER EDUCATION

                    Subpart A--National Initiatives

     SEC. 10101. ADVANCE CARE PLANNING TELEPHONE HOTLINE.

       (a) In General.--Not later than January 1, 2011, the 
     Secretary, acting through the Director of the Centers for 
     Disease Control and Prevention, shall establish and operate 
     directly, or by grant, contract, or interagency agreement, a 
     24-hour toll-free telephone hotline to provide consumer 
     information regarding advance care planning, including--

[[Page 31830]]

       (1) an explanation of advanced care planning and its 
     importance;
       (2) issues to be considered when developing an individual's 
     advance care plan;
       (3) how to establish an advance directive;
       (4) procedures to help ensure that an individual's 
     directives for end-of-life care are followed;
       (5) Federal and State-specific resources for assistance 
     with advance care planning; and
       (6) hospice and palliative care (including their respective 
     purposes and services).
       (b) Establishment.--In carrying out the requirements under 
     subsection (a), the Director of the Centers for Disease 
     Control and Prevention may designate an existing 24-hour 
     toll-free telephone hotline or, if no such service is 
     available or appropriate, establish a new 24-hour toll-free 
     telephone hotline.

     SEC. 10102. ADVANCE CARE PLANNING INFORMATION CLEARINGHOUSES.

       (a) Expansion of National Clearinghouse for Long-Term Care 
     Information.--
       (1) Development.--Not later than January 1, 2010, the 
     Secretary shall develop an online clearinghouse to provide 
     comprehensive information regarding advance care planning.
       (2) Maintenance.--The advance care planning clearinghouse, 
     which shall be clearly identifiable and available on the 
     homepage of the Department of Health and Human Service's 
     National Clearinghouse for Long-Term Care Information 
     website, shall be maintained and publicized by the Secretary 
     on an ongoing basis.
       (3) Content.--The advance care planning clearinghouse shall 
     include--
       (A) any relevant content contained in the national public 
     education campaign required under section 10104;
       (B) content addressing--
       (i) an explanation of advanced care planning and its 
     importance;
       (ii) issues to be considered when developing an 
     individual's advance care plan;
       (iii) how to establish an advance directive;
       (iv) procedures to help ensure that an individual's 
     directives for end-of-life care are followed; and
       (v) hospice and palliative care (including their respective 
     purposes and services); and
       (C) available Federal and State-specific resources for 
     assistance with advance care planning, including--
       (i) contact information for any State public health 
     departments that are responsible for issues regarding end-of-
     life care;
       (ii) contact information for relevant legal service 
     organizations, including those funded under the Older 
     Americans Act of 1965 (42 U.S.C. 3001 et seq.); and
       (iii) advance directive forms for each State; and
       (D) any additional information, as determined by the 
     Secretary.
       (b) Establishment of Pediatric Advance Care Planning 
     Clearinghouse.--
       (1) Development.--Not later than January 1, 2011, the 
     Secretary, in consultation with the Assistant Secretary for 
     Children and Families of the Department of Health and Human 
     Services, shall develop an online clearinghouse to provide 
     comprehensive information regarding pediatric advance care 
     planning.
       (2) Maintenance.--The pediatric advance care planning 
     clearinghouse, which shall be clearly identifiable on the 
     homepage of the Administration for Children and Families 
     website, shall be maintained and publicized by the Secretary 
     on an ongoing basis.
       (3) Content.--The pediatric advance care planning 
     clearinghouse shall provide advance care planning information 
     specific to children with life-threatening illnesses or 
     injuries and their families.

     SEC. 10103. ADVANCE CARE PLANNING TOOLKIT.

       (a) Development.--Not later than July 1, 2010, the 
     Secretary, in consultation with the Director of the Centers 
     for Disease Control and Prevention, shall develop an online 
     advance care planning toolkit.
       (b) Maintenance.--The advance care planning toolkit, which 
     shall be available in English, Spanish, and any other 
     languages that the Secretary deems appropriate, shall be 
     maintained and publicized by the Secretary on an ongoing 
     basis and made available on the following websites:
       (1) The Centers for Disease Control and Prevention.
       (2) The Department of Health and Human Service's National 
     Clearinghouse for Long-Term Care Information.
       (3) The Administration for Children and Families.
       (c) Content.--The advance care planning toolkit shall 
     include content addressing--
       (1) common issues and questions regarding advance care 
     planning, including individuals and resources to contact for 
     further inquiries;
       (2) advance directives and their uses, including living 
     wills and durable powers of attorney;
       (3) the roles and responsibilities of a health care proxy;
       (4) Federal and State-specific resources to assist 
     individuals and their families with advance care planning, 
     including--
       (A) the advance care planning toll-free telephone hotline 
     established under section 10101;
       (B) the advance care planning clearinghouses established 
     under section 10102;
       (C) the advance care planning toolkit established under 
     this section;
       (D) available State legal service organizations to assist 
     individuals with advance care planning, including those 
     organizations that receive funding pursuant to the Older 
     Americans Act of 1965 (42 U.S.C. 3001 et seq.); and
       (E) website links or addresses for State-specific advance 
     directive forms; and
       (5) any additional information, as determined by the 
     Secretary.

     SEC. 10104. NATIONAL PUBLIC EDUCATION CAMPAIGN.

       (a) National Public Education Campaign.--
       (1) In general.--Not later than January 1, 2011, the 
     Secretary, acting through the Director of the Centers for 
     Disease Control and Prevention, shall, directly or through 
     grants, contracts, or interagency agreements, develop and 
     implement a national campaign to inform the public of the 
     importance of advance care planning and of an individual's 
     right to direct and participate in their health care 
     decisions.
       (2) Content of educational campaign.--The national public 
     education campaign established under paragraph (1) shall--
       (A) employ the use of various media, including regularly 
     televised public service announcements;
       (B) provide culturally and linguistically appropriate 
     information;
       (C) be conducted continuously over a period of not less 
     than 5 years;
       (D) identify and promote the advance care planning 
     information available on the Department of Health and Human 
     Service's National Clearinghouse for Long-Term Care 
     Information website and Administration for Children and 
     Families website, as well as any other relevant Federal or 
     State-specific advance care planning resources;
       (E) raise public awareness of the consequences that may 
     result if an individual is no longer able to express or 
     communicate their health care decisions;
       (F) address the importance of individuals speaking to 
     family members, health care proxies, and health care 
     providers as part of an ongoing dialogue regarding their 
     health care choices;
       (G) address the need for individuals to obtain readily 
     available legal documents that express their health care 
     decisions through advance directives (including living wills, 
     comfort care orders, and durable powers of attorney for 
     health care);
       (H) raise public awareness regarding the availability of 
     hospice and palliative care; and
       (I) encourage individuals to speak with their physicians 
     about their options and intentions for end-of-life care.
       (3) Evaluation.--
       (A) In general.--Not later than July 1, 2013, the 
     Secretary, acting through the Director of the Centers for 
     Disease Control and Prevention, shall conduct a nationwide 
     survey to evaluate whether the national campaign conducted 
     under this subsection has achieved its goal of changing 
     public awareness, attitudes, and behaviors regarding advance 
     care planning.
       (B) Baseline survey.--In order to evaluate the 
     effectiveness of the national campaign, the Secretary shall 
     conduct a baseline survey prior to implementation of the 
     campaign.
       (C) Reporting requirement.--Not later than December 31, 
     2013, the Secretary shall report the findings of such survey, 
     as well as any recommendations that the Secretary determines 
     appropriate regarding the need for continuation or 
     legislative or administrative changes to facilitate changing 
     public awareness, attitudes, and behaviors regarding advance 
     care planning, to the appropriate committees of the Congress.
       (b) Repeal.--Section 4751(d) of the Omnibus Budget 
     Reconciliation Act of 1990 (42 U.S.C. 1396a note; Public Law 
     101-508) is repealed.

     SEC. 10105. UPDATE OF MEDICARE AND SOCIAL SECURITY HANDBOOKS.

       (a) Medicare & You Handbook.--
       (1) In general.--Not later than 60 days after the date of 
     enactment of this Act, the Secretary shall update the online 
     version of the ``Planning Ahead'' section of the Medicare & 
     You Handbook to include--
       (A) an explanation of advance care planning and advance 
     directives, including--
       (i) living wills;
       (ii) health care proxies; and
       (iii) after-death directives;
       (B) Federal and State-specific resources to assist 
     individuals and their families with advance care planning, 
     including--
       (i) the advance care planning toll-free telephone hotline 
     established under section 10101;
       (ii) the advance care planning clearinghouses established 
     under section 10102;
       (iii) the advance care planning toolkit established under 
     section 10103;
       (iv) available State legal service organizations to assist 
     individuals with advance care planning, including those 
     organizations that receive funding pursuant to the Older 
     Americans Act of 1965 (42 U.S.C. 3001 et seq.); and
       (v) website links or addresses for State-specific advance 
     directive forms; and
       (C) any additional information, as determined by the 
     Secretary.
       (2) Update of paper and subsequent versions.--The Secretary 
     shall include the

[[Page 31831]]

     information described in paragraph (1) in all paper and 
     electronic versions of the Medicare & You Handbook that are 
     published on or after the date that is 60 days after the date 
     of enactment of this Act.
       (b) Social Security Handbook.--The Commissioner of Social 
     Security shall--
       (1) not later than 60 days after the date of enactment of 
     this Act, update the online version of the Social Security 
     Handbook for beneficiaries to include the information 
     described in subsection (a)(1); and
       (2) include such information in all paper and online 
     versions of such handbook that are published on or after the 
     date that is 60 days after the date of enactment of this Act.

     SEC. 10106. AUTHORIZATION OF APPROPRIATIONS.

       There is authorized to be appropriated for the period of 
     fiscal years 2010 through 2014--
       (1) $195,000,000 to the Secretary to carry out sections 
     10101, 10102, 10103, 10104 and 10105(a); and
       (2) $5,000,000 to the Commissioner of Social Security to 
     carry out section 10105(b).

                 Subpart B--State and Local Initiatives

     SEC. 10111. FINANCIAL ASSISTANCE FOR ADVANCE CARE PLANNING.

       (a) Legal Assistance for Advance Care Planning.--
       (1) Definition of recipient.--Section 1002(6) of the Legal 
     Services Corporation Act (42 U.S.C. 2996a(6)) is amended by 
     striking ``clause (A) of'' and inserting ``subparagraph (A) 
     or (B) of''.
       (2) Advance care planning.--Section 1006 of the Legal 
     Services Corporation Act (42 U.S.C. 2996e) is amended--
       (A) in subsection (a)(1)--
       (i) by striking ``title, and (B) to make'' and inserting 
     the following: ``title;
       ``(C) to make''; and
       (ii) by inserting after subparagraph (A) the following:
       ``(B) to provide financial assistance, and make grants and 
     contracts, as described in subparagraph (A), on a competitive 
     basis for the purpose of providing legal assistance in the 
     form of advance care planning (as defined in section 10002 of 
     the Patient Protection and Affordable Care Act, and including 
     providing information about State-specific advance 
     directives, as defined in that section) for eligible clients 
     under this title, including providing such planning to the 
     family members of eligible clients and persons with power of 
     attorney to make health care decisions for the clients; 
     and''; and
       (B) in subsection (b), by adding at the end the following:
       ``(2) Advance care planning provided in accordance with 
     subsection (a)(1)(B) shall not be construed to violate the 
     Assisted Suicide Funding Restriction Act of 1997 (42 U.S.C. 
     14401 et seq.).''.
       (3) Reports.--Section 1008(a) of the Legal Services 
     Corporation Act (42 U.S.C. 2996g(a)) is amended by adding at 
     the end the following: ``The Corporation shall require such a 
     report, on an annual basis, from each grantee, contractor, or 
     other recipient of financial assistance under section 
     1006(a)(1)(B).''.
       (4) Authorization of appropriations.--Section 1010 of the 
     Legal Services Corporation Act (42 U.S.C. 2996i) is amended--
       (A) in subsection (a)--
       (i) by striking ``(a)'' and inserting ``(a)(1)'';
       (ii) in the last sentence, by striking ``Appropriations for 
     that purpose'' and inserting the following:
       ``(3) Appropriations for a purpose described in paragraph 
     (1) or (2)''; and
       (iii) by inserting before paragraph (3) (as designated by 
     clause (ii)) the following:
       ``(2) There are authorized to be appropriated to carry out 
     section 1006(a)(1)(B), $10,000,000 for each of fiscal years 
     2010, 2011, 2012, 2013, and 2014.''; and
       (B) in subsection (d), by striking ``subsection (a)'' and 
     inserting ``subsection (a)(1)''.
       (5) Effective date.--This subsection and the amendments 
     made by this subsection take effect July 1, 2010.
       (b) State Health Insurance Assistance Programs.--
       (1) In general.--The Secretary shall use amounts made 
     available under paragraph (3) to award grants to States for 
     State health insurance assistance programs receiving 
     assistance under section 4360 of the Omnibus Budget 
     Reconciliation Act of 1990 to provide advance care planning 
     services to Medicare beneficiaries, personal representatives 
     of such beneficiaries, and the families of such 
     beneficiaries. Such services shall include information 
     regarding State-specific advance directives and ways to 
     discuss individual care wishes with health care providers.
       (2) Requirements.--
       (A) Award of grants.--In making grants under this 
     subsection for a fiscal year, the Secretary shall satisfy the 
     following requirements:
       (i) Two-thirds of the total amount of funds available under 
     paragraph (3) for a fiscal year shall be allocated among 
     those States approved for a grant under this section that 
     have adopted the Uniform Health-Care Decisions Act drafted by 
     the National Conference of Commissioners on Uniform State 
     Laws and approved and recommended for enactment by all States 
     at the annual conference of such commissioners in 1993.
       (ii) One-third of the total amount of funds available under 
     paragraph (3) for a fiscal year shall be allocated among 
     those States approved for a grant under this section that 
     have adopted a uniform form regarding orders regarding life 
     sustaining treatment (as described in section 10002) or a 
     comparable approach to advance care planning.
       (B) Work plan; report.--As a condition of being awarded a 
     grant under this subsection, a State shall submit the 
     following to the Secretary:
       (i) An approved plan for expending grant funds.
       (ii) For each fiscal year for which the State is paid grant 
     funds under this subsection, an annual report regarding the 
     use of the funds, including the number of Medicare 
     beneficiaries served and their satisfaction with the services 
     provided.
       (C) Limitation.--No State shall be paid funds from a grant 
     made under this subsection prior to July 1, 2010.
       (3) Authorization of appropriations.--There is authorized 
     to be appropriated to the Secretary to the Centers for 
     Medicare & Medicaid Services Program Management Account, 
     $12,000,000 for each of fiscal years 2010 through 2014 for 
     purposes of awarding grants to States under paragraph (1).
       (c) Medicaid Transformation Grants for Advance Care 
     Planning.--Section 1903(z) of the Social Security Act (42 
     U.S.C. 1396b(z)) is amended--
       (1) in paragraph (2), by adding at the end the following 
     new subparagraph:
       ``(G) Methods for improving the effectiveness and 
     efficiency of medical assistance provided under this title by 
     making available to individuals enrolled in the State plan or 
     under a waiver of such plan information regarding advance 
     care planning (as defined in section 10002 of the Patient 
     Protection and Affordable Care Act), including at time of 
     enrollment or renewal of enrollment in the plan or waiver, 
     through providers, and through such other innovative means as 
     the State determines appropriate.'';
       (2) in paragraph (3), by adding at the end the following 
     new subparagraph:
       ``(D) Work plan required for award of advance care planning 
     grants.--Payment to a State under this subsection to adopt 
     the innovative methods described in paragraph (2)(G) is 
     conditioned on the State submitting to the Secretary an 
     approved plan for expending the funds awarded to the State 
     under this subsection.''; and
       (3) in paragraph (4)--
       (A) in subparagraph (A)--
       (i) in clause (i), by striking ``and'' at the end;
       (ii) in clause (ii), by striking the period at the end and 
     inserting ``; and''; and
       (iii) by inserting after clause (ii), the following new 
     clause:
       ``(iii) $20,000,000 for each of fiscal years 2010 through 
     2014.''; and
       (B) by striking subparagraph (B), and inserting the 
     following:
       ``(B) Allocation of funds.--The Secretary shall specify a 
     method for allocating the funds made available under this 
     subsection among States awarded a grant for fiscal year 2010, 
     2011, 2012, 2013, or 2014. Such method shall provide that--
       ``(i) 100 percent of such funds for each of fiscal years 
     2010 through 2014 shall be awarded to States that design 
     programs to adopt the innovative methods described in 
     paragraph (2)(G); and
       ``(ii) in no event shall a payment to a State awarded a 
     grant under this subsection for fiscal year 2010 be made 
     prior to July 1, 2010.''.
       (d) Advance Care Planning Community Training Grants.--
       (1) In general.--The Secretary shall use amounts made 
     available under paragraph (3) to award grants to area 
     agencies on aging (as defined in section 102 of the Older 
     Americans Act of 1965 (42 U.S.C. 3002)).
       (2) Requirements.--
       (A) Use of funds.--Funds awarded to an area agency on aging 
     under this subsection shall be used to provide advance care 
     planning education and training opportunities for local aging 
     service providers and organizations.
       (B) Work plan; report.--As a condition of being awarded a 
     grant under this subsection, an area agency on aging shall 
     submit the following to the Secretary:
       (i) An approved plan for expending grant funds.
       (ii) For each fiscal year for which the agency is paid 
     grant funds under this subsection, an annual report regarding 
     the use of the funds, including the number of Medicare 
     beneficiaries served and their satisfaction with the services 
     provided.
       (C) Limitation.--No area agency on aging shall be paid 
     funds from a grant made under this subsection prior to July 
     1, 2010.
       (3) Authorization of appropriations.--There is authorized 
     to be appropriated to the Secretary to the Centers for 
     Medicare & Medicaid Services Program Management Account, 
     $12,000,000 for each of fiscal years 2010 through 2014 for 
     purposes of awarding grants to area agencies on aging under 
     paragraph (1).
       (e) Nonduplication of Activities.--The Secretary shall 
     establish procedures to ensure that funds made available 
     under grants awarded under this section or pursuant to

[[Page 31832]]

     amendments made by this section supplement, not supplant, 
     existing Federal funding, and that such funds are not used to 
     duplicate activities carried out under such grants or under 
     other Federally funded programs.

     SEC. 10112. GRANTS FOR PROGRAMS FOR ORDERS REGARDING LIFE 
                   SUSTAINING TREATMENT.

       (a) In General.--The Secretary shall make grants to 
     eligible entities for the purpose of--
       (1) establishing new programs for orders regarding life 
     sustaining treatment in States or localities;
       (2) expanding or enhancing an existing program for orders 
     regarding life sustaining treatment in States or localities; 
     or
       (3) providing a clearinghouse of information on programs 
     for orders for life sustaining treatment and consultative 
     services for the development or enhancement of such programs.
       (b) Authorized Activities.--Activities funded through a 
     grant under this section for an area may include--
       (1) developing such a program for the area that includes 
     home care, hospice, long-term care, community and assisted 
     living residences, skilled nursing facilities, inpatient 
     rehabilitation facilities, hospitals, and emergency medical 
     services within the area;
       (2) securing consultative services and advice from 
     institutions with experience in developing and managing such 
     programs; and
       (3) expanding an existing program for orders regarding life 
     sustaining treatment to serve more patients or enhance the 
     quality of services, including educational services for 
     patients and patients' families or training of health care 
     professionals.
       (c) Distribution of Funds.--In funding grants under this 
     section, the Secretary shall ensure that, of the funds 
     appropriated to carry out this section for each fiscal year--
       (1) at least two-thirds are used for establishing or 
     developing new programs for orders regarding life sustaining 
     treatment; and
       (2) one-third is used for expanding or enhancing existing 
     programs for orders regarding life sustaining treatment.
       (d) Definitions.--In this section:
       (1) The term ``eligible entity'' includes--
       (A) an academic medical center, a medical school, a State 
     health department, a State medical association, a multi-State 
     taskforce, a hospital, or a health system capable of 
     administering a program for orders regarding life sustaining 
     treatment for a State or locality; or
       (B) any other health care agency or entity as the Secretary 
     determines appropriate.
       (2) The term ``order regarding life sustaining treatment'' 
     means, with respect to an individual, an actionable medical 
     order relating to the treatment of that individual that--
       (A) is signed and dated by a physician (as defined in 
     section 1861(r)(1) of the Social Security Act (42 U.S.C. 
     1395x(r)(1))) or another health care professional (as 
     specified by the Secretary and who is acting within the scope 
     of the professional's authority under State law in signing 
     such an order) and is in a form that permits it to stay with 
     the patient and be followed by health care professionals and 
     providers across the continuum of care, including home care, 
     hospice, long-term care, community and assisted living 
     residences, skilled nursing facilities, inpatient 
     rehabilitation facilities, hospitals, and emergency medical 
     services;
       (B) effectively communicates the individual's preferences 
     regarding life sustaining treatment, including an indication 
     of the treatment and care desired by the individual;
       (C) is uniquely identifiable and standardized within a 
     given locality, region, or State (as identified by the 
     Secretary);
       (D) is portable across care settings; and
       (E) may incorporate any advance directive (as defined in 
     section 1866(f)(3) of the Social Security Act (42 U.S.C. 
     1395cc(f)(3)) if executed by the individual. .
       (3) The term ``program for orders regarding life sustaining 
     treatment'' means, with respect to an area, a program that 
     supports the active use of orders regarding life sustaining 
     treatment in the area.
       (e) Authorization of Appropriations.--To carry out this 
     section, there are authorized to be appropriated such sums as 
     may be necessary for each of the fiscal years 2009 through 
     2014.

                      PART II--PROVIDER EDUCATION

     SEC. 10121. PUBLIC PROVIDER ADVANCE CARE PLANNING WEBSITE.

       (a) Development.--Not later than January 1, 2010, the 
     Secretary, acting through the Administrator of the Centers 
     for Medicare & Medicaid Services and the Director of the 
     Agency for Healthcare Research and Quality, shall establish a 
     website for providers under Medicare, Medicaid, the 
     Children's Health Insurance Program, the Indian Health 
     Service (include contract providers) and other public health 
     providers on each individual's right to make decisions 
     concerning medical care, including the right to accept or 
     refuse medical or surgical treatment, and the existence of 
     advance directives.
       (b) Maintenance.--The website, shall be maintained and 
     publicized by the Secretary on an ongoing basis.
       (c) Content.--The website shall include content, tools, and 
     resources necessary to do the following:
       (1) Inform providers about the advance directive 
     requirements under the health care programs described in 
     subsection (a) and other State and Federal laws and 
     regulations related to advance care planning.
       (2) Educate providers about advance care planning quality 
     improvement activities.
       (3) Provide assistance to providers to--
       (A) integrate advance directives into electronic health 
     records, including oral directives; and
       (B) develop and disseminate advance care planning 
     informational materials for their patients.
       (4) Inform providers about advance care planning continuing 
     education requirements and opportunities.
       (5) Encourage providers to discuss advance care planning 
     with their patients of all ages.
       (6) Assist providers' understanding of the continuum of 
     end-of-life care services and supports available to patients, 
     including palliative care and hospice.
       (7) Inform providers of best practices for discussing end-
     of-life care with dying patients and their loved ones.

     SEC. 10122. CONTINUING EDUCATION FOR PHYSICIANS AND NURSES.

       (a) In General.--Not later than January 1, 2012, the 
     Secretary, acting through the Director of Health Resources 
     and Services Administration, shall develop, in consultation 
     with health care providers and State boards of medicine and 
     nursing, a curriculum for continuing education that States 
     may adopt for physicians and nurses on advance care planning 
     and end-of-life care.
       (b) Content.--
       (1) In general.--The continuing education curriculum 
     developed under subsection (a) for physicians and nurses 
     shall, at a minimum, include--
       (A) a description of the meaning and importance of advance 
     care planning;
       (B) a description of advance directives, including living 
     wills and durable powers of attorney, and the use of such 
     directives;
       (C) palliative care principles and approaches to care; and
       (D) the continuum of end-of-life services and supports, 
     including palliative care and hospice.
       (2) Additional content for physicians.--The continuing 
     education curriculum for physicians developed under 
     subsection (a) shall include instruction on how to conduct 
     advance care planning with patients and their loved ones.

   Subtitle B--Portability of Advance Directives; Health Information 
                               Technology

     SEC. 10131. PORTABILITY OF ADVANCE DIRECTIVES.

       (a) Medicare.--Section 1866(f) of the Social Security Act 
     (42 U.S.C. 1395cc(f)) is amended--
       (1) in paragraph (1)--
       (A) in subparagraph (B), by inserting ``and if presented by 
     the individual, to include the content of such advance 
     directive in a prominent part of such record'' before the 
     semicolon at the end;
       (B) in subparagraph (D), by striking ``and'' after the 
     semicolon at the end;
       (C) in subparagraph (E), by striking the period at the end 
     and inserting ``; and''; and
       (D) by inserting after subparagraph (E) the following new 
     subparagraph:
       ``(F) to provide each individual with the opportunity to 
     discuss issues relating to the information provided to that 
     individual pursuant to subparagraph (A) with an appropriately 
     trained professional.'';
       (2) in paragraph (3), by striking ``a written'' and 
     inserting ``an''; and
       (3) by adding at the end the following new paragraph:
       ``(5)(A) An advance directive validly executed outside of 
     the State in which such advance directive is presented by an 
     adult individual to a provider of services, a Medicare 
     Advantage organization, or a prepaid or eligible organization 
     shall be given the same effect by that provider or 
     organization as an advance directive validly executed under 
     the law of the State in which it is presented would be given 
     effect.
       ``(B)(i) The definition of an advanced directive shall also 
     include actual knowledge of instructions made while an 
     individual was able to express the wishes of such individual 
     with regard to health care.
       ``(ii) For purposes of clause (i), the term `actual 
     knowledge' means the possession of information of an 
     individual's wishes communicated to the health care provider 
     orally or in writing by the individual, the individual's 
     medical power of attorney representative, the individual's 
     health care surrogate, or other individuals resulting in the 
     health care provider's personal cognizance of these wishes. 
     Other forms of imputed knowledge are not actual knowledge.
       ``(C) The provisions of this paragraph shall preempt any 
     State law to the extent such law is inconsistent with such 
     provisions. The provisions of this paragraph shall not 
     preempt any State law that provides for greater portability, 
     more deference to a patient's wishes, or more latitude in 
     determining a patient's wishes.''.
       (b) Medicaid.--Section 1902(w) of the Social Security Act 
     (42 U.S.C. 1396a(w)) is amended--
       (1) in paragraph (1)--
       (A) in subparagraph (B)--
       (i) by striking ``in the individual's medical record'' and 
     inserting ``in a prominent part

[[Page 31833]]

     of the individual's current medical record''; and
       (ii) by inserting ``and if presented by the individual, to 
     include the content of such advance directive in a prominent 
     part of such record'' before the semicolon at the end;
       (B) in subparagraph (D), by striking ``and'' after the 
     semicolon at the end;
       (C) in subparagraph (E), by striking the period at the end 
     and inserting ``; and''; and
       (D) by inserting after subparagraph (E) the following new 
     subparagraph:
       ``(F) to provide each individual with the opportunity to 
     discuss issues relating to the information provided to that 
     individual pursuant to subparagraph (A) with an appropriately 
     trained professional.'';
       (2) in paragraph (4), by striking ``a written'' and 
     inserting ``an''; and
       (3) by adding at the end the following paragraph:
       ``(6)(A) An advance directive validly executed outside of 
     the State in which such advance directive is presented by an 
     adult individual to a provider or organization shall be given 
     the same effect by that provider or organization as an 
     advance directive validly executed under the law of the State 
     in which it is presented would be given effect.
       ``(B)(i) The definition of an advance directive shall also 
     include actual knowledge of instructions made while an 
     individual was able to express the wishes of such individual 
     with regard to health care.
       ``(ii) For purposes of clause (i), the term `actual 
     knowledge' means the possession of information of an 
     individual's wishes communicated to the health care provider 
     orally or in writing by the individual, the individual's 
     medical power of attorney representative, the individual's 
     health care surrogate, or other individuals resulting in the 
     health care provider's personal cognizance of these wishes. 
     Other forms of imputed knowledge are not actual knowledge.
       ``(C) The provisions of this paragraph shall preempt any 
     State law to the extent such law is inconsistent with such 
     provisions. The provisions of this paragraph shall not 
     preempt any State law that provides for greater portability, 
     more deference to a patient's wishes, or more latitude in 
     determining a patient's wishes.''.
       (c) CHIP.--Section 2107(e)(1) of the Social Security Act 
     (42 U.S.C. 1397gg(e)(1)), as amended by sections 2101(d)(2), 
     2101(e), and 6401(c), is further amended--
       (1) by redesignating subparagraphs (G) through (N) as 
     subparagraphs (H) through (O), respectively; and
       (2) by inserting after subparagraph (F) the following:
       ``(G) Section 1902(w) (relating to advance directives).''.
       (d) Study and Report Regarding Implementation.--
       (1) Study.--The Secretary shall conduct a study regarding 
     the implementation of the amendments made by subsections (a) 
     and (b).
       (2) Report.--Not later than 18 months after the date of 
     enactment of this Act, the Secretary shall submit to Congress 
     a report on the study conducted under paragraph (1), together 
     with recommendations for such legislation and administrative 
     actions as the Secretary considers appropriate.
       (e) Effective Dates.--
       (1) In general.--Subject to paragraph (2), the amendments 
     made by subsections (a), (b), and (c) shall apply to provider 
     agreements and contracts entered into, renewed, or extended 
     under title XVIII of the Social Security Act (42 U.S.C. 1395 
     et seq.), and to State plans under title XIX of such Act (42 
     U.S.C. 1396 et seq.) and State child health plans under title 
     XXI of such Act (42 U.S.C. 1397aa et seq.), on or after such 
     date as the Secretary specifies, but in no case may such date 
     be later than 1 year after the date of enactment of this Act.
       (2) Extension of effective date for state law amendment.--
     In the case of a State plan under title XIX of the Social 
     Security Act or a State child health plan under title XXI of 
     such Act which the Secretary determines requires State 
     legislation in order for the plan to meet the additional 
     requirements imposed by the amendments made by subsections 
     (b) and (c), 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 these additional requirements 
     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 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 the 
     session is considered to be a separate regular session of the 
     State legislature.

     SEC. 10132. STATE ADVANCE DIRECTIVE REGISTRIES; DRIVER'S 
                   LICENSE ADVANCE DIRECTIVE NOTATION.

       Part P of title III of the Public Health Service Act (42 
     U.S.C. 280g) is amended by adding at the end the following:

     ``SEC. 399X. STATE ADVANCE DIRECTIVE REGISTRIES.

       ``(a) State Advance Directive Registry.--In this section, 
     the term `State advance directive registry' means a secure, 
     electronic database that--
       ``(1) is available free of charge to residents of a State; 
     and
       ``(2) stores advance directive documents and makes such 
     documents accessible to medical service providers in 
     accordance with Federal and State privacy laws.
       ``(b) Grant Program.--Beginning on July 1, 2010, the 
     Secretary, acting through the Director of the Centers for 
     Disease Control and Prevention, shall award grants on a 
     competitive basis to eligible entities to establish and 
     operate, directly or indirectly (by competitive grant or 
     competitive contract), State advance directive registries.
       ``(c) Eligible Entities.--
       ``(1) In general.--To be eligible to receive a grant under 
     this section, an entity shall--
       ``(A) be a State department of health; and
       ``(B) submit to the Director an application at such time, 
     in such manner, and containing--
       ``(i) a plan for the establishment and operation of a State 
     advance directive registry; and
       ``(ii) such other information as the Director may require.
       ``(2) No requirement of notation mechanism.--The Secretary 
     shall not require that an entity establish and operate a 
     driver's license advance directive notation mechanism for 
     State residents under section 399Y to be eligible to receive 
     a grant under this section.
       ``(d) Annual Report.--For each year for which an entity 
     receives an award under this section, such entity shall 
     submit an annual report to the Director on the use of the 
     funds received pursuant to such award, including the number 
     of State residents served through the registry.
       ``(e) Authorization.--There is authorized to be 
     appropriated to carry out this section $20,000,000 for fiscal 
     year 2010 and each fiscal year thereafter.

     ``SEC. 399Y. DRIVER'S LICENSE ADVANCE DIRECTIVE NOTATION.

       ``(a) In General.--Beginning July 1, 2010, the Secretary, 
     acting through the Director of the Centers for Disease 
     Control and Prevention, shall award grants on a competitive 
     basis to States to establish and operate a mechanism for a 
     State resident with a driver's license to include a notice of 
     the existence of an advance directive for such resident on 
     such license.
       ``(b) Eligibility.--To be eligible to receive a grant under 
     this section, a State shall--
       ``(1) establish and operate a State advance directive 
     registry under section 399X; and
       ``(2) submit to the Director an application at such time, 
     in such manner, and containing--
       ``(A) a plan that includes a description of how the State 
     will--
       ``(i) disseminate information about advance directives at 
     the time of driver's license application or renewal;
       ``(ii) enable each State resident with a driver's license 
     to include a notice of the existence of an advance directive 
     for such resident on such license in a manner consistent with 
     the notice on such a license indicating a driver's intent to 
     be an organ donor; and
       ``(iii) coordinate with the State department of health to 
     ensure that, if a State resident has an advance directive 
     notice on his or her driver's license, the existence of such 
     advance directive is included in the State registry 
     established under section 399X; and
       ``(B) any other information as the Director may require.
       ``(c) Annual Report.--For each year for which a State 
     receives an award under this section, such State shall submit 
     an annual report to the Director on the use of the funds 
     received pursuant to such award, including the number of 
     State residents served through the mechanism.
       ``(d) Authorization.--There is authorized to be 
     appropriated to carry out this section $50,000,000 for fiscal 
     year 2010 and each fiscal year thereafter.''.

     SEC. 10133. GAO STUDY AND REPORT ON ESTABLISHMENT OF NATIONAL 
                   ADVANCE DIRECTIVE REGISTRY.

       (a) Study.--The Comptroller General of the United States 
     shall conduct a study on the feasibility of a national 
     registry for advance directives, taking into consideration 
     the constraints created by the privacy provisions enacted as 
     a result of the Health Insurance Portability and 
     Accountability Act of 1996 (Public Law 104-191).
       (b) 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 on the study 
     conducted under subsection (a) together with recommendations 
     for such legislation and administrative action as the 
     Comptroller General of the United States determines to be 
     appropriate.

      Subtitle C--National Uniform Policy on Advance Care Planning

     SEC. 10141. STUDY AND REPORT BY THE SECRETARY REGARDING THE 
                   ESTABLISHMENT AND IMPLEMENTATION OF A NATIONAL 
                   UNIFORM POLICY ON ADVANCE DIRECTIVES.

       (a) Study.--
       (1) In general.--The Secretary, acting through the Office 
     of the Assistant Secretary for Planning and Evaluation, shall 
     conduct a thorough study of all matters relating to the 
     establishment and implementation of a national uniform policy 
     on advance directives for individuals receiving items and 
     services under titles XVIII, XIX, or XXI of the Social

[[Page 31834]]

     Security Act (42 U.S.C. 1395 et seq.; 1396 et seq.; 1397aa et 
     seq.).
       (2) Matters studied.--The matters studied by the Secretary 
     under paragraph (1) shall include issues concerning--
       (A) family satisfaction that a patient's wishes, as stated 
     in the patient's advance directive, were carried out;
       (B) the portability of advance directives, including cases 
     involving the transfer of an individual from 1 health care 
     setting to another;
       (C) immunity from civil liability and criminal 
     responsibility for health care providers that follow the 
     instructions in an individual's advance directive that was 
     validly executed in, and consistent with the laws of, the 
     State in which it was executed;
       (D) conditions under which an advance directive is 
     operative;
       (E) revocation of an advance directive by an individual;
       (F) the criteria used by States for determining that an 
     individual has a terminal condition;
       (G) surrogate decisionmaking regarding end-of-life care;
       (H) the provision of adequate palliative care (as defined 
     in paragraph (3)), including pain management;
       (I) adequate and timely referrals to hospice care programs; 
     and
       (J) the end-of-life care needs of children and their 
     families.
       (3) Palliative care.--For purposes of paragraph (2)(H), the 
     term ``palliative care'' means interdisciplinary care for 
     individuals with a life-threatening illness or injury 
     relating to pain and symptom management and psychological, 
     social, and spiritual needs and that seeks to improve the 
     quality of life for the individual and the individual's 
     family.
       (b) Report to Congress.--Not later than 18 months after the 
     date of enactment of this Act, the Secretary shall submit to 
     Congress a report on the study conducted under subsection 
     (a), together with recommendations for such legislation and 
     administrative actions as the Secretary considers 
     appropriate.
       (c) Consultation.--In conducting the study and developing 
     the report under this section, the Secretary shall consult 
     with the Uniform Law Commissioners, and other interested 
     parties.

          Subtitle D--Compassionate Care Workforce Development

     SEC. 10151. EXEMPTION OF PALLIATIVE MEDICINE FELLOWSHIP 
                   TRAINING FROM MEDICARE GRADUATE MEDICAL 
                   EDUCATION CAPS.

       (a) Direct Graduate Medical Education.--Section 
     1886(h)(4)(F) of the Social Security Act (42 U.S.C. 
     1395ww(h)(4)(F)), as amended by section 5503(a)(1), is 
     amended--
       (1) in clause (i), by inserting ``clause (iii) and'' after 
     ``subject to''; and
       (2) by adding at the end the following new clause:
       ``(iii) Increase allowed for palliative medicine fellowship 
     training.--For cost reporting periods beginning on or after 
     January 1, 2011, in applying clause (i), there shall not be 
     taken into account full-time equivalent residents in the 
     field of allopathic or osteopathic medicine who are in 
     palliative medicine fellowship training that is approved by 
     the Accreditation Council for Graduate Medical Education.''.
       (b) Indirect Medical Education.--Section 1886(d)(5)(B) of 
     the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)), as 
     amended by sections 5503(b)(2) and 5505(b), is further 
     amended by adding at the end the following new clause:
       ``(xi) Clause (iii) of subsection (h)(4)(F) shall apply to 
     clause (v) in the same manner and for the same period as such 
     clause (iii) applies to clause (i) of such subsection.''.

     SEC. 10152. MEDICAL SCHOOL CURRICULA.

       (a) In General.--The Secretary, in consultation with the 
     Association of American Medical Colleges, shall establish 
     guidelines for the imposition by medical schools of a minimum 
     amount of end-of-life training as a requirement for obtaining 
     a Doctor of Medicine degree in the field of allopathic or 
     osteopathic medicine.
       (b) Training.--Under the guidelines established under 
     subsection (a), minimum training shall include--
       (1) training in how to discuss and help patients and their 
     loved ones with advance care planning;
       (2) with respect to students and trainees who will work 
     with children, specialized pediatric training;
       (3) training in the continuum of end-of-life services and 
     supports, including palliative care and hospice;
       (4) training in how to discuss end-of-life care with dying 
     patients and their loved ones; and
       (5) medical and legal issues training.
       (c) Distribution.--Not later than January 1, 2011, the 
     Secretary shall disseminate the guidelines established under 
     subsection (a) to medical schools.
       (d) Compliance.--Effective beginning not later than July 1, 
     2012, a medical school that is receiving Federal assistance 
     shall be required to implement the guidelines established 
     under subsection (a). A medical school that the Secretary 
     determines is not implementing such guidelines shall not be 
     eligible for Federal assistance.

       Subtitle E--Additional Reports, Research, and Evaluations

     SEC. 10161. NATIONAL MORTALITY FOLLOWBACK SURVEY.

       (a) In General.--Not later than December 31, 2010, and 
     annually thereafter, the Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     shall renew and conduct the National Mortality Followback 
     Survey (referred to in this section as the ``Survey'') to 
     collect data on end-of-life care.
       (b) Purpose.--The purpose of the Survey shall be to gain a 
     better understanding of current end-of-life care in the 
     United States.
       (c) Questions.--
       (1) In general.--In conducting the Survey, the Director of 
     the Centers for Disease Control and Prevention shall, at a 
     minimum, include the following questions with respect to the 
     loved one of a respondent:
       (A) Did he or she have an advance directive, and if so, 
     when it was completed.
       (B) Did he or she have an order for life-sustaining 
     treatment, and if so, when was it completed.
       (C) Did he or she have a durable power of attorney, and if 
     so, when it was completed.
       (D) Had he or she discussed his or her wishes with loved 
     ones, and if so, when.
       (E) Had he or she discussed his or her wishes with his or 
     her physician, and if so, when.
       (F) In the opinion of the respondent, was he or she 
     satisfied with the care he or she received in the last year 
     of life and in the last week of life.
       (G) Was he or she cared for by hospice, and if so, when.
       (H) Was he or she cared for by palliative care specialists, 
     and if so, when.
       (I) Did he or she receive effective pain management (if 
     needed).
       (J) What was the experience of the main caregiver 
     (including if such caregiver was the respondent), and whether 
     he or she received sufficient support in this role.
       (2) Additional questions.--Additional questions to be asked 
     during the Survey shall be determined by the Director of the 
     Centers for Disease Control and Prevention on an ongoing 
     basis with input from relevant research entities.

     SEC. 10162. INSPECTOR GENERAL INVESTIGATION OF FRAUD AND 
                   ABUSE.

       In accordance with the recommendations of the Medicare 
     Payment Advisory Commission for additional data (as contained 
     in the March 2009 report entitled ``Report to Congress: 
     Medicare Payment Policy''), the Secretary shall direct the 
     Office of the Inspector General of the Department of Health 
     and Human Services to investigate, not later than January 1, 
     2012, the following with respect to hospice benefit under 
     Medicare, Medicaid, and CHIP:
       (1) The prevalence of financial relationships between 
     hospices and long-term care facilities, such as nursing 
     facilities and assisted living facilities, that may represent 
     a conflict of interest and influence admissions to hospice.
       (2) Differences in patterns of nursing home referrals to 
     hospice.
       (3) The appropriateness of enrollment practices for 
     hospices with unusual utilization patterns (such as high 
     frequency of very long stays, very short stays, or enrollment 
     of patients discharged from other hospices).
       (4) The appropriateness of hospice marketing materials and 
     other admissions practices and potential correlations between 
     length of stay and deficiencies in marketing or admissions 
     practices.

     SEC. 10163. GAO STUDY AND REPORT ON PROVIDER ADHERENCE TO 
                   ADVANCE DIRECTIVES.

       Not later than January 1, 2012, the Comptroller General of 
     the United States shall conduct a study of the extent to 
     which providers comply with advance directives under the 
     Medicare and Medicaid programs and shall submit a report to 
     Congress on the results of such study, together with such 
     recommendations for administrative or legislative changes as 
     the Comptroller General determines appropriate.
                                 ______
                                 
  SA 3240. Mr. ROCKEFELLER (for himself, Mr. Lieberman, Mr. Whitehouse, 
and Mr. Bingaman) submitted an amendment intended to be proposed to 
amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. 
Dodd, and Mr. Harkin) to 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; which was ordered to lie on the 
table; as follows:

       On page 1053, between lines 2 and 3, insert the following:

     SEC. 3403A. IMPROVEMENTS TO THE INDEPENDENT MEDICARE ADVISORY 
                   BOARD.

       Section 1899A of the Social Security Act, as added by 
     section 3403, is amended--
       (1) in subsection (c)--
       (A) in paragraph (2)(A), by striking clause (iii) and 
     inserting the following new clause:
       ``(iii) As appropriate, the proposal may include 
     recommendations to adjust payments with respect to all 
     providers of services (as defined in section 1861(u)) and 
     suppliers (as defined in section 1861(d)).'';

[[Page 31835]]

       (B) in paragraph (3)(A)(ii)--
       (i) in subclause (I), by inserting ``or'' at the end;
       (ii) in subclause (II), by striking ``; or'' at the end and 
     inserting a period; and
       (iii) by striking subclause (III);
       (C) in paragraph (7)(C), by striking clause (i) and 
     inserting the following new clause:
       ``(i) in the case of implementation year 2015 or any 
     subsequent implementation year, 1.5 percent; and''; and
       (D) by striking paragraph (8);
       (2) in subsection (e), by striking ``August 15'' each place 
     it appears and inserting ``June 1'';
       (3) in subsection (f)(3)(B), by striking ``or advisory 
     reports to Congress'' and inserting ``, advisory reports, or 
     other reports'';
       (4) by redesignating subsections (g) through (m) as 
     subsections (i) through (o), respectively; and
       (5) by adding at the end the following new subsections:
       ``(g) Proposals in Non-Determination Years.--
       ``(1) In general.--In any proposal year in which the Board 
     is not required to transmit a proposal to the President by 
     reason of the application of subclause (I) or (II) of 
     subsection (c)(3)(A)(ii), the Board shall transmit a proposal 
     under this section to the President on January 15 of the 
     year. Except as provided in paragraph (2), such a proposal 
     shall be treated as a proposal under this section and all of 
     the provisions of this section with respect to proposals, 
     including the requirements under paragraphs (2) and (4) of 
     subsection (c) and the required Congressional consideration 
     under subsection (d), shall apply to the proposal.
       ``(2) Exceptions.--The following rules shall apply to a 
     proposal transmitted pursuant to paragraph (1):
       ``(A) Recommendations for achieving target.--The 
     requirement under subsection (c)(2)(A)(i) shall not apply.
       ``(B) Required information.--The proposal shall not 
     include--
       ``(i) recommendations described in subsection (c)(2)(A)(i), 
     pursuant to subsection (c)(3)(B)(i); or
       ``(ii) an actuarial opinion by the Chief Actuary of the 
     Centers for Medicare & Medicaid Services certifying that the 
     proposal meets the requirements of subsection (c)(2)(A)(i), 
     pursuant to subsection (c)(3)(B)(iii);
       ``(C) Contingent secretarial proposal.--The Secretary shall 
     not submit a proposal if the Board fails to submit a proposal 
     pursuant to subsection (c)(5).
       ``(D) Congressional consideration.--
       ``(i) Subparagraphs (A) and (B) of subsection (d)(3) shall 
     be applied by substituting `subsection (c)(2)(C)' for 
     `subparagraphs (A)(i) and (C) of subsection (c)(2)'.
       ``(ii) Subparagraphs (D) and (E) of subsection (d)(3) and 
     subsection (d)(4)(B)(v) shall be applied by requiring a 
     simple majority rather than three-fifths of the Members duly 
     chosen and sworn.
       ``(iii) Subsection (d)(4)(B)(iv) shall not apply.
       ``(iv) Subsection (d)(4)(C)(v)(II) shall be applied by 
     substituting `subsection (c)(2)(C)' for `subparagraphs (A)(i) 
     and (C) of subsection (c)(2)'.
       ``(v) Subsection (d)(4)(E)(iv)(II) shall be applied by 
     substituting `subsection (c)(2)(C)' for `subparagraphs (A)(i) 
     and (C) of subsection (c)(2)'.
       ``(E) Secretarial implementation.--Subsection (e) shall not 
     apply and the Secretary shall not implement the 
     recommendations contained in the proposal unless the 
     Secretary otherwise has the authority to implement such 
     recommendations.
       ``(h) Annual Report With Recommendations With Respect to 
     the Private Sector.--
       ``(1) In general.--Not later than July 1, 2014, and January 
     15, 2015, and annually thereafter, the Board shall submit to 
     Congress, the Secretary, and the Medicaid and CHIP Payment 
     and Access Commission a report that includes recommendations 
     on--
       ``(A) requirements under the program under this title (or 
     requirements included in the proposal submitted under this 
     section in the year); and
       ``(B) in the case of any report submitted in a year after a 
     determination year (beginning with determination year 2017) 
     in which the Chief Actuary of the Centers for Medicare & 
     Medicaid Services has made a determination described in 
     subclause (I) or (II) of subsection (c)(3)(A)(ii), other 
     requirements determined appropriate by the Board;

     that should be included in the requirements established under 
     section 1311(c) of the Patient Protection and Affordable Care 
     Act for a health plan to be certified as a qualified health 
     plan, such as requirements that improve the health care 
     delivery system and health outcomes (including by promoting 
     integrated care, care coordination, prevention and wellness, 
     and quality and efficiency), decrease health care spending, 
     and other appropriate improvements
       ``(2) Incorporation into certification requirements.--
       ``(A) In general.--The Secretary shall review the 
     recommendations contained in the report submitted to the 
     Secretary by the Board under paragraph (1). The Secretary 
     may, if determined appropriate, incorporate such 
     recommendations into the requirements for certification under 
     such section 1311(c).
       ``(B) Report to congress.--Not later than December 31, 
     2014, and June 15, 2015, and annually thereafter, the 
     Secretary shall submit to Congress a report on the 
     application of subparagraph (A). Such report shall include, 
     with respect to each recommendation contained in a report 
     submitted by the Board in that year, a description of whether 
     or not the Secretary incorporated the recommendation into the 
     requirements for certification under such section 1311(c), 
     and if not, the reasons why.
       ``(3) MACPAC.--The Medicaid and CHIP Payment and Access 
     Commission shall--
       ``(A) review whether or not recommendations contained in a 
     report submitted to the Commission by the Board under 
     paragraph (1) would improve the Medicaid program under title 
     XIX and the Children's Health Insurance Program under title 
     XXI if implemented under such programs; and
       ``(B) include in the Commission's annual report to Congress 
     the results of such review.''.
                                 ______
                                 
  SA 3241. Mr. CARPER (for himself, Mr. Conrad, and Mrs. Shaheen) 
submitted an amendment intended to be proposed to amendment SA 2786 
proposed by Mr. Reid (for himself, Mr. Baucus, Mr. Dodd, and Mr. 
Harkin) to 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; which was ordered to lie on the table; as follows:

       On page 722, after line 20, insert the following:

     SEC. 3016. INTEGRATED HEALTH CARE SYSTEM COLLABORATION 
                   INITIATIVE.

       (a) In General.--In order to improve health care quality 
     and reduce costs, the Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     develop, in consultation with major integrated health systems 
     that have consistently demonstrated high quality and low cost 
     (as determined by the Secretary and verified by a third 
     party) a collaboration initiative (referred to in this 
     section as ``the Collaborative''). The Collaborative shall 
     develop an exportable model of optimal health care delivery 
     to apply value-based measurement, integrated information 
     technology infrastructure, standard care pathways, and 
     population-based payment models, to measurably improve health 
     care quality, outcomes, and patient satisfaction and achieve 
     cost savings.
       (b) Participation.--Prior to January 1, 2010, the Secretary 
     shall determine 5 initial participants who will form the 
     Collaborative and at least 6 additional participants who will 
     join the Collaborative beginning in the fourth year that the 
     Collaborative is in effect.
       (1) Initial participants.--Initial participants selected by 
     the Secretary shall meet the following criteria:
       (A) Be integrated health systems organized for the purpose 
     of providing health care services.
       (B) Have demonstrated a record of providing high value 
     health care for at least the 5 previous years, as determined 
     by the Secretary in consultation with the Medicare Payment 
     Advisory Commission.
       (C) Agree to participate in the Medicare shared savings 
     program under section 1899 of the Social Security Act, as 
     added by section 3022, the National pilot program on payment 
     bundling under section 1866D of such Act, as added by section 
     3023, or a program under the Center for Medicare and Medicaid 
     Innovation under section 1115A of such Act, as added by 
     section 3021.
       (D) Any additional criteria specified by the Secretary.
       (2) Additional participants.--Beginning January 1, 2013, 
     the Secretary shall select 6 or more additional participants 
     who represent diverse geographic areas and are situated in 
     areas of differing population densities who agree to comply 
     with the guidelines, processes, and requirements set forth 
     for the Collaborative. Such additional participants shall 
     meet the following additional criteria:
       (A) Be organized for the provision of patient medical care.
       (B) Be capable of implementing infrastructure and health 
     care delivery modifications necessary to enhance health care 
     quality and efficiency, as determined by the Secretary in 
     consultation with the Medicare Payment Advisory Commission.
       (C) The participant's cost and intensity of care do not 
     meet the definition of high value health care.
       (D) Agree to participate in the Medicare shared savings 
     program under section 1899 of the Social Security Act, as 
     added by section 3022, the National pilot program on payment 
     bundling under section 1866D of such Act, as added by section 
     3023, or a program under the Center for Medicare and Medicaid 
     Innovation under section 1115A of such Act, as added by 
     section 3021.
       (E) The participant would benefit from such participation 
     (as determined by the

[[Page 31836]]

     Secretary, based on the likelihood that the participant would 
     improve its performance under section 1886(p) of the Social 
     Security Act, as added by section 3008, section 1886(q) of 
     such Act, as added by section 3025, or any similar program 
     under title XVIII of the Social Security Act).
       (3) Additional criteria.--In addition to the criteria 
     described in paragraphs (1) and (2), the participants in the 
     Collaborative shall meet the following criteria:
       (A) Agree to report on quality, cost, and efficiency in 
     such form, manner, and frequency as specified by the 
     Secretary.
       (B) Provide care to patients enrolled in the Medicare 
     program.
       (C) Agree to contribute to a best practices network and 
     website, that is maintained by the Collaborative for sharing 
     strategies on quality improvement, care coordination, 
     efficiency, and effectiveness.
       (D) Use patient-centered processes of care, including those 
     that emphasize patient and caregiver involvement in shared 
     decision-making for treatment decisions.
       (E) Meet other criteria determined to be appropriate by the 
     Secretary.
       (c) Collaborative Initiative.--
       (1) In general.--Beginning January 1, 2010, the 
     Collaborative shall begin a 2 year development phase in which 
     initial participants share the quantitative and qualitative 
     methods through which they have developed high value health 
     care followed by a dissemination of that learning model to 
     additional participants of the Collaborative.
       (2) Coordinating member.--In consultation with the 
     Secretary, the Collaborative shall select a coordinating 
     member organization (hereafter identified as the Coordinating 
     Organization) of the Collaborative.
       (3) Qualifications.--The Coordinating Organization will 
     have in place a comprehensive Medicare database and possess 
     experience using and analyzing Medicare data to measure 
     health care utilization, cost, and variation. The 
     Coordinating Organization shall be responsible for reporting 
     to the Secretary as required and for any other requirements 
     deemed necessary by the Secretary.
       (4) Responsibilities.--The Coordinating Member shall--
       (A) lead efforts to develop each aspect of the learning 
     model;
       (B) organize efforts to disseminate the learning model for 
     high value health care, including educating participant 
     institutions; and
       (C) provide administrative, technical, accounting, 
     reporting, organizational and infrastructure support needed 
     to carry out the goals of the Collaborative.
       (5) Development of learning model.--
       (A) In general.--Initial participants in the Collaborative 
     shall work together to develop a learning model based on 
     their experience that includes a reliance on evidence based 
     care that emphasizes quality and practice techniques that 
     emphasize efficiency, joint development and implementation of 
     health information technology, introduction of clinical 
     microsystems of care, shared decision-making, outcomes and 
     measurement, and the establishment of an e-learning 
     distributive network, which have been put into practice at 
     their respective institutions.
       (B) Responsibilities.--The Coordinating Member shall do the 
     following:
       (i) Partner with initial participants to comprehensively 
     understand each institution's contribution to providing 
     value-based health care.
       (ii) Provide and measure value-based health care in a 
     manner that ensures that measures are aligned with current 
     measures approved by a consensus-based organization, such as 
     the National Quality Forum, or other measures as determined 
     appropriate by the Secretary, while also incorporating 
     patient self-reported status and outcomes.
       (iii) Create a replicable and scalable infrastructure for 
     common measurement of value-based care that can be broadly 
     disseminated across the Collaborative and other institutions.
       (iv) Implement care pathways for common conditions using 
     standard measures for assessment across institutions, 
     targeting high variation and high cost conditions, including 
     but not limited to--

       (I) acute myocardial infarction (AMI) and angioplasty;
       (II) coronary artery bypass graft surgery and percutaneous 
     coronary intervention;
       (III) hip or knee replacement;
       (IV) spinal surgery; and
       (V) care for chronic diseases including, but not limited 
     to, diabetes, heart disease, and high blood pressure.

       (v) Deploy and disseminate the comprehensive learning model 
     across initial participant institutions, achieving 
     improvements in care delivery and lowering costs, and 
     demonstrating the portability and viability of the processes.
       (6) Additional best practices.--As additional methods of 
     improving health care quality and efficiency are identified 
     by members of the Collaborative or by other institutions, 
     Initial Participants in the Collaborative shall incorporate 
     those practices into the learning model.
       (d) Implementation of Learning Model.--Beginning January 1, 
     2013, as additional participants are selected by the 
     Secretary, Initial Participants in the Collaborative shall 
     actively engage in the deployment of the learning model to 
     educate each additional participant in the common conditions 
     that have been identified.
       (1) Dissemination of learning model.--Dissemination methods 
     shall include but not be limited to the following methods:
       (A) Specialized teams deployed by the Initial Participants 
     to teach and facilitate implementation on site.
       (B) Distance-learning, taking advantage of latest 
     interactive technologies.
       (C) On-line, fully accessible repositories of shared 
     learning and information related to best practices.
       (D) Advanced population health information technology 
     models.
       (2) Evaluation of participants.--
       (A) In general.--Evaluation of initial participants shall 
     be based on documented success in meeting quality and 
     efficiency measurements. Specific statistically valid 
     measures of evaluation shall be determined by the Secretary.
       (B) Performance targets.--The Secretary shall develop 
     performance targets for participants. Performance targets 
     developed under the preceding sentence shall be based on 
     whether participants have improved their performance under 
     section 1886(p) of the Social Security Act, as added by 
     section 3008, section 1886(q) of such Act, as added by 
     section 3025, or any similar program under title XVIII of the 
     Social Security Act (as determined by the Secretary).
       (e) Measurement of Learning Model.--Participants shall 
     implement techniques under the comprehensive learning model. 
     The Secretary shall determine whether such implementation 
     improves quality and efficiency, including cost savings 
     relative to baseline spending for the common conditions 
     specified under subsection (c)(5)(B)(iv) and quality measures 
     endorsed by a consensus-based organization or otherwise 
     chosen by the Secretary. The Collaborative shall prepare a 
     report annually on each participant's performance with 
     respect to the efficiency and quality measurements 
     established by the Secretary. Such report shall be submitted 
     to the Secretary and Congress and shall be made publicly 
     available.
       (f) Administrative Payment.--For purposes of carrying out 
     this section, there are authorized to be appropriated 
     $228,000,000, to remain available until expended. Amounts 
     appropriated under the preceding sentence shall be 
     distributed in the following manner:
       (1) The Coordinating Organization shall receive $10,000,000 
     per year for program development related to the 
     Collaborative, including for health information technology 
     and other infrastructure, project evaluations, analysis, and 
     measurement, compliance, auditings and other reporting. Not 
     less than $5,000,000 of such funds shall be provided for 
     education and training, including for support for the 
     establishment of training teams for the Collaborative, to 
     assist in the integration of new health information 
     technology, best practices of care delivery, microsystems of 
     care delivery, and a distributive e-learning network for the 
     Collaborative.
       (2) Each Initial Participant shall receive $4,000,000 per 
     year for internal program development for health information 
     technology and other infrastructure, education and training, 
     project evaluations, analysis, and measurement, and 
     compliance, auditing, and other reporting.
       (3) Beginning in 2013, the Secretary may provide funding to 
     additional participants in the Collaborative in an amount not 
     to exceed $4,000,000 per participant per year under the same 
     use guidelines as apply to the Initial Participants.
       (g) Continuation or Expansion.--
       (1) Termination.--Subject to paragraph (2), the 
     Collaborative shall terminate on the date that is 6 years 
     after the date on which the Collaborative is established.
       (2) Expansion.--The Secretary may continue or expand the 
     Collaborative if the Collaborative is consistently exceeding 
     quality standards and is not increasing spending under the 
     program.
       (h) Termination.--The Secretary may terminate an agreement 
     with a participating organization under the Collaborative if 
     such organization consistently failed to meet quality 
     standards in the fourth year or any subsequent year of the 
     Collaborative
       (i) Reports.--
       (1) Performance results reports.--The Secretary shall 
     provide such data as is necessary for the Collaborative to 
     measure the efficacy of the Collaborative and facilitate 
     regular reporting on spending and cost savings results 
     relative to a value-based program initiative.
       (2) Reports to congress.--Not later than 2 years after the 
     date the first agreement is entered into under this section, 
     and annually thereafter, the Secretary shall submit to 
     Congress and make publicly available a report on the 
     authority granted to the Secretary to carry out the 
     Collaborative under this section. Each report shall address 
     the impact of the use of such authority on expenditures for, 
     access to, and quality of, care under title XVIII of the 
     Social Security Act.
       (j) Definitions.--In this section:
       (1) Beneficiary.--The term ``beneficiary'' means a Medicare 
     beneficiary enrolled under part B and entitled to benefits 
     under part A who is not enrolled in Medicare Advantage

[[Page 31837]]

     under Part C or a PACE program under section 1894, and meets 
     other criteria as the Secretary determines appropriate.
       (2) High value health care.--The term ``high value health 
     care'' means the care delivered by organizations shown by 
     statistically valid methods to meet the highest quality 
     measures established by the Secretary as of or after the date 
     of enactment of this Act and to be delivering low-cost care 
     with high patient satisfaction and clinical outcomes.
       (3) Learning model.--The term ``learning model'' means a 
     standardized model developed by the Initial Participants in 
     the Collaborative and based on best practices, as jointly 
     developed and put into practice at the Initial Participant's 
     respective institutions.
       (4) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (k) Additional Monitoring.--The Secretary may monitor data 
     on expenditures and quality of services under title XVIII of 
     the Social Security Act with respect to a beneficiary after 
     the beneficiary discontinues receiving services under the 
     Collaborative.
       (l) Other Provisions.--
       (1) Limitations on review.--There shall be no 
     administrative or judicial review under this section or 
     otherwise of--
       (A) the elements, parameters, scope, and duration of the 
     Collaborative, including the selection of participants in the 
     Collaborative;
       (B) the establishment of targets, measurement of 
     performance;
       (C) determinations with respect to whether savings have 
     been achieved and the amount of savings; and
       (D) decisions about the extension or expansion of the 
     Collaborative.
       (2) Administration.--Chapter 35 of title 44, 4 United 
     States Code shall not apply to this section.
       (3) Monitoring.--The Inspector General of the Department of 
     Health and Human Services shall provide for monitoring of the 
     operation of the Collaborative with regard to violations of 
     section 1877 of the Social Security Act (popularly known as 
     the ``Stark law'').
       (4) Anti-discrimination.--The Secretary shall not enter 
     into an agreement with an entity to provide health care items 
     or services under the Collaborative, or with an entity to 
     administer the Collaborative, unless such entity guarantees 
     that it will not deny, limit, or condition the coverage or 
     provision of benefits under the Collaborative for 
     beneficiaries to participate in the Collaborative, based on 
     any health status-related factor described in section 
     2702(a)(1) of the Public Health Service Act.

                          ____________________