[Congressional Record (Bound Edition), Volume 155 (2009), Part 24]
[Senate]
[Pages 32751-32818]
[From the U.S. Government Publishing Office, www.gpo.gov]




                           TEXT OF AMENDMENTS

                                 ______
                                 
  SA 3276. Mr. REID (for himself, Mr. Baucus, Mr. Dodd, and Mr. Harkin) 
proposed an amendment 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, strike lines 22 through 25, and insert the 
     following:
       (f) Effective Date.--The amendments made by subsections (a) 
     through (d) of this section shall apply to amounts paid or 
     incurred after December 31, 2008, in taxable years beginning 
     after such date.

    TITLE X--STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL 
                               AMERICANS

               Subtitle A--Provisions Relating to Title I

     SEC. 10101. AMENDMENTS TO SUBTITLE A.

       (a) Section 2711 of the Public Health Service Act, as added 
     by section 1001(5) of this Act, is amended to read as 
     follows:

     ``SEC. 2711. NO LIFETIME OR ANNUAL LIMITS.

       ``(a) Prohibition.--
       ``(1) In general.--A group health plan and a health 
     insurance issuer offering group or individual health 
     insurance coverage may not establish--
       ``(A) lifetime limits on the dollar value of benefits for 
     any participant or beneficiary; or
       ``(B) except as provided in paragraph (2), annual limits on 
     the dollar value of benefits for any participant or 
     beneficiary.
       ``(2) Annual limits prior to 2014.--With respect to plan 
     years beginning prior to January 1, 2014, a group health plan 
     and a health insurance issuer offering group or individual 
     health insurance coverage may only establish a restricted 
     annual limit on the dollar value of benefits for any 
     participant or beneficiary with respect to the scope of 
     benefits that are essential health benefits under section 
     1302(b) of the Patient Protection and Affordable Care Act, as 
     determined by the Secretary. In defining the term `restricted 
     annual limit' for purposes of the preceding sentence, the 
     Secretary shall ensure that access to needed services is made 
     available with a minimal impact on premiums.
       ``(b) Per Beneficiary Limits.--Subsection (a) shall not be 
     construed to prevent a group health plan or health insurance 
     coverage from placing annual or lifetime per beneficiary 
     limits on specific covered benefits that are not essential 
     health benefits under section 1302(b) of the Patient 
     Protection and Affordable Care Act, to the extent that such 
     limits are otherwise permitted under Federal or State law.''.
       (b) Section 2715(a) of the Public Health Service Act, as 
     added by section 1001(5) of this Act, is amended by striking 
     ``and providing to enrollees'' and inserting ``and providing 
     to applicants, enrollees, and policyholders or certificate 
     holders''.
       (c) Subpart II of part A of title XXVII of the Public 
     Health Service Act, as added by section 1001(5), is amended 
     by inserting after section 2715, the following:

     ``SEC. 2715A. PROVISION OF ADDITIONAL INFORMATION.

       ``A group health plan and a health insurance issuer 
     offering group or individual health insurance coverage shall 
     comply with the provisions of section 1311(e)(3) of the 
     Patient Protection and Affordable Care Act, except that a 
     plan or coverage that is not offered through an Exchange 
     shall only be required to submit the information required to 
     the Secretary and the State insurance commissioner, and make 
     such information available to the public.''.
       (d) Section 2716 of the Public Health Service Act, as added 
     by section 1001(5) of this Act, is amended to read as 
     follows:

     ``SEC. 2716. PROHIBITION ON DISCRIMINATION IN FAVOR OF HIGHLY 
                   COMPENSATED INDIVIDUALS.

       ``(a) In General.--A group health plan (other than a self-
     insured plan) shall satisfy the requirements of section 
     105(h)(2) of the Internal Revenue Code of 1986 (relating to 
     prohibition on discrimination in favor of highly compensated 
     individuals).
       ``(b) Rules and Definitions.--For purposes of this 
     section--
       ``(1) Certain rules to apply.--Rules similar to the rules 
     contained in paragraphs (3), (4), and (8) of section 105(h) 
     of such Code shall apply.
       ``(2) Highly compensated individual.--The term `highly 
     compensated individual' has the meaning given such term by 
     section 105(h)(5) of such Code.''.
       (e) Section 2717 of the Public Health Service Act, as added 
     by section 1001(5) of this Act, is amended--
       (1) by redesignating subsections (c) and (d) as subsections 
     (d) and (e), respectively; and
       (2) by inserting after subsection (b), the following:
       ``(c) Protection of Second Amendment Gun Rights.--
       ``(1) Wellness and prevention programs.--A wellness and 
     health promotion activity implemented under subsection 
     (a)(1)(D) may not require the disclosure or collection of any 
     information relating to--
       ``(A) the presence or storage of a lawfully-possessed 
     firearm or ammunition in the residence or on the property of 
     an individual; or
       ``(B) the lawful use, possession, or storage of a firearm 
     or ammunition by an individual.
       ``(2) Limitation on data collection.--None of the 
     authorities provided to the Secretary

[[Page 32752]]

     under the Patient Protection and Affordable Care Act or an 
     amendment made by that Act shall be construed to authorize or 
     may be used for the collection of any information relating 
     to--
       ``(A) the lawful ownership or possession of a firearm or 
     ammunition;
       ``(B) the lawful use of a firearm or ammunition; or
       ``(C) the lawful storage of a firearm or ammunition.
       ``(3) Limitation on databases or data banks.--None of the 
     authorities provided to the Secretary under the Patient 
     Protection and Affordable Care Act or an amendment made by 
     that Act shall be construed to authorize or may be used to 
     maintain records of individual ownership or possession of a 
     firearm or ammunition.
       ``(4) Limitation on determination of premium rates or 
     eligibility for health insurance.--A premium rate may not be 
     increased, health insurance coverage may not be denied, and a 
     discount, rebate, or reward offered for participation in a 
     wellness program may not be reduced or withheld under any 
     health benefit plan issued pursuant to or in accordance with 
     the Patient Protection and Affordable Care Act or an 
     amendment made by that Act on the basis of, or on reliance 
     upon--
       ``(A) the lawful ownership or possession of a firearm or 
     ammunition; or
       ``(B) the lawful use or storage of a firearm or ammunition.
       ``(5) Limitation on data collection requirements for 
     individuals.--No individual shall be required to disclose any 
     information under any data collection activity authorized 
     under the Patient Protection and Affordable Care Act or an 
     amendment made by that Act relating to--
       ``(A) the lawful ownership or possession of a firearm or 
     ammunition; or
       ``(B) the lawful use, possession, or storage of a firearm 
     or ammunition.''.
       (f) Section 2718 of the Public Health Service Act, as added 
     by section 1001(5), is amended to read as follows:

     ``SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE COVERAGE.

       ``(a) Clear Accounting for Costs.--A health insurance 
     issuer offering group or individual health insurance coverage 
     (including a grandfathered health plan) shall, with respect 
     to each plan year, submit to the Secretary a report 
     concerning the ratio of the incurred loss (or incurred 
     claims) plus the loss adjustment expense (or change in 
     contract reserves) to earned premiums. Such report shall 
     include the percentage of total premium revenue, after 
     accounting for collections or receipts for risk adjustment 
     and risk corridors and payments of reinsurance, that such 
     coverage expends--
       ``(1) on reimbursement for clinical services provided to 
     enrollees under such coverage;
       ``(2) for activities that improve health care quality; and
       ``(3) on all other non-claims costs, including an 
     explanation of the nature of such costs, and excluding 
     Federal and State taxes and licensing or regulatory fees.
     The Secretary shall make reports received under this section 
     available to the public on the Internet website of the 
     Department of Health and Human Services.
       ``(b) Ensuring That Consumers Receive Value for Their 
     Premium Payments.--
       ``(1) Requirement to provide value for premium payments.--
       ``(A) Requirement.--Beginning not later than January 1, 
     2011, a health insurance issuer offering group or individual 
     health insurance coverage (including a grandfathered health 
     plan) shall, with respect to each plan year, provide an 
     annual rebate to each enrollee under such coverage, on a pro 
     rata basis, if the ratio of the amount of premium revenue 
     expended by the issuer on costs described in paragraphs (1) 
     and (2) of subsection (a) to the total amount of premium 
     revenue (excluding Federal and State taxes and licensing or 
     regulatory fees and after accounting for payments or receipts 
     for risk adjustment, risk corridors, and reinsurance under 
     sections 1341, 1342, and 1343 of the Patient Protection and 
     Affordable Care Act) for the plan year (except as provided in 
     subparagraph (B)(ii)), is less than--
       ``(i) with respect to a health insurance issuer offering 
     coverage in the large group market, 85 percent, or such 
     higher percentage as a State may by regulation determine; or
       ``(ii) with respect to a health insurance issuer offering 
     coverage in the small group market or in the individual 
     market, 80 percent, or such higher percentage as a State may 
     by regulation determine, except that the Secretary may adjust 
     such percentage with respect to a State if the Secretary 
     determines that the application of such 80 percent may 
     destabilize the individual market in such State.
       ``(B) Rebate amount.--
       ``(i) Calculation of amount.--The total amount of an annual 
     rebate required under this paragraph shall be in an amount 
     equal to the product of--

       ``(I) the amount by which the percentage described in 
     clause (i) or (ii) of subparagraph (A) exceeds the ratio 
     described in such subparagraph; and
       ``(II) the total amount of premium revenue (excluding 
     Federal and State taxes and licensing or regulatory fees and 
     after accounting for payments or receipts for risk 
     adjustment, risk corridors, and reinsurance under sections 
     1341, 1342, and 1343 of the Patient Protection and Affordable 
     Care Act) for such plan year.

       ``(ii) Calculation based on average ratio.--Beginning on 
     January 1, 2014, the determination made under subparagraph 
     (A) for the year involved shall be based on the averages of 
     the premiums expended on the costs described in such 
     subparagraph and total premium revenue for each of the 
     previous 3 years for the plan.
       ``(2) Consideration in setting percentages.--In determining 
     the percentages under paragraph (1), a State shall seek to 
     ensure adequate participation by health insurance issuers, 
     competition in the health insurance market in the State, and 
     value for consumers so that premiums are used for clinical 
     services and quality improvements.
       ``(3) Enforcement.--The Secretary shall promulgate 
     regulations for enforcing the provisions of this section and 
     may provide for appropriate penalties.
       ``(c) Definitions.--Not later than December 31, 2010, and 
     subject to the certification of the Secretary, the National 
     Association of Insurance Commissioners shall establish 
     uniform definitions of the activities reported under 
     subsection (a) and standardized methodologies for calculating 
     measures of such activities, including definitions of which 
     activities, and in what regard such activities, constitute 
     activities described in subsection (a)(2). Such methodologies 
     shall be designed to take into account the special 
     circumstances of smaller plans, different types of plans, and 
     newer plans.
       ``(d) Adjustments.--The Secretary may adjust the rates 
     described in subsection (b) if the Secretary determines 
     appropriate on account of the volatility of the individual 
     market due to the establishment of State Exchanges.
       ``(e) Standard Hospital Charges.--Each hospital operating 
     within the United States shall for each year establish (and 
     update) and make public (in accordance with guidelines 
     developed by the Secretary) a list of the hospital's standard 
     charges for items and services provided by the hospital, 
     including for diagnosis-related groups established under 
     section 1886(d)(4) of the Social Security Act.''.
       (g) Section 2719 of the Public Health Service Act, as added 
     by section 1001(4) of this Act, is amended to read as 
     follows:

     ``SEC. 2719. APPEALS PROCESS.

       ``(a) Internal Claims Appeals.--
       ``(1) In general.--A group health plan and a health 
     insurance issuer offering group or individual health 
     insurance coverage shall implement an effective appeals 
     process for appeals of coverage determinations and claims, 
     under which the plan or issuer shall, at a minimum--
       ``(A) have in effect an internal claims appeal process;
       ``(B) provide notice to enrollees, in a culturally and 
     linguistically appropriate manner, of available internal and 
     external appeals processes, and the availability of any 
     applicable office of health insurance consumer assistance or 
     ombudsman established under section 2793 to assist such 
     enrollees with the appeals processes; and
       ``(C) allow an enrollee to review their file, to present 
     evidence and testimony as part of the appeals process, and to 
     receive continued coverage pending the outcome of the appeals 
     process.
       ``(2) Established processes.--To comply with paragraph 
     (1)--
       ``(A) a group health plan and a health insurance issuer 
     offering group health coverage shall provide an internal 
     claims and appeals process that initially incorporates the 
     claims and appeals procedures (including urgent claims) set 
     forth at section 2560.503-1 of title 29, Code of Federal 
     Regulations, as published on November 21, 2000 (65 Fed. Reg. 
     70256), and shall update such process in accordance with any 
     standards established by the Secretary of Labor for such 
     plans and issuers; and
       ``(B) a health insurance issuer offering individual health 
     coverage, and any other issuer not subject to subparagraph 
     (A), shall provide an internal claims and appeals process 
     that initially incorporates the claims and appeals procedures 
     set forth under applicable law (as in existence on the date 
     of enactment of this section), and shall update such process 
     in accordance with any standards established by the Secretary 
     of Health and Human Services for such issuers.
       ``(b) External Review.--A group health plan and a health 
     insurance issuer offering group or individual health 
     insurance coverage--
       ``(1) shall comply with the applicable State external 
     review process for such plans and issuers that, at a minimum, 
     includes the consumer protections set forth in the Uniform 
     External Review Model Act promulgated by the National 
     Association of Insurance Commissioners and is binding on such 
     plans; or
       ``(2) shall implement an effective external review process 
     that meets minimum standards established by the Secretary 
     through guidance and that is similar to the process described 
     under paragraph (1)--

[[Page 32753]]

       ``(A) if the applicable State has not established an 
     external review process that meets the requirements of 
     paragraph (1); or
       ``(B) if the plan is a self-insured plan that is not 
     subject to State insurance regulation (including a State law 
     that establishes an external review process described in 
     paragraph (1)).
       ``(c) Secretary Authority.--The Secretary may deem the 
     external review process of a group health plan or health 
     insurance issuer, in operation as of the date of enactment of 
     this section, to be in compliance with the applicable process 
     established under subsection (b), as determined appropriate 
     by the Secretary.''.
       (h) Subpart II of part A of title XVIII of the Public 
     Health Service Act, as added by section 1001(5) of this Act, 
     is amended by inserting after section 2719 the following:

     ``SEC. 2719A. PATIENT PROTECTIONS.

       ``(a) Choice of Health Care Professional.--If a group 
     health plan, or a health insurance issuer offering group or 
     individual health insurance coverage, requires or provides 
     for designation by a participant, beneficiary, or enrollee of 
     a participating primary care provider, then the plan or 
     issuer shall permit each participant, beneficiary, and 
     enrollee to designate any participating primary care provider 
     who is available to accept such individual.
       ``(b) Coverage of Emergency Services.--
       ``(1) In general.--If a group health plan, or a health 
     insurance issuer offering group or individual health 
     insurance issuer, provides or covers any benefits with 
     respect to services in an emergency department of a hospital, 
     the plan or issuer shall cover emergency services (as defined 
     in paragraph (2)(B))--
       ``(A) without the need for any prior authorization 
     determination;
       ``(B) whether the health care provider furnishing such 
     services is a participating provider with respect to such 
     services;
       ``(C) in a manner so that, if such services are provided to 
     a participant, beneficiary, or enrollee--
       ``(i) by a nonparticipating health care provider with or 
     without prior authorization; or
       ``(ii)(I) such services will be provided without imposing 
     any requirement under the plan for prior authorization of 
     services or any limitation on coverage where the provider of 
     services does not have a contractual relationship with the 
     plan for the providing of services that is more restrictive 
     than the requirements or limitations that apply to emergency 
     department services received from providers who do have such 
     a contractual relationship with the plan; and
       ``(II) if such services are provided out-of-network, the 
     cost-sharing requirement (expressed as a copayment amount or 
     coinsurance rate) is the same requirement that would apply if 
     such services were provided in-network;
       ``(D) without regard to any other term or condition of such 
     coverage (other than exclusion or coordination of benefits, 
     or an affiliation or waiting period, permitted under section 
     2701 of this Act, section 701 of the Employee Retirement 
     Income Security Act of 1974, or section 9801 of the Internal 
     Revenue Code of 1986, and other than applicable cost-
     sharing).
       ``(2) Definitions.--In this subsection:
       ``(A) Emergency medical condition.--The term `emergency 
     medical condition' means a medical condition manifesting 
     itself by acute symptoms of sufficient severity (including 
     severe pain) such that a prudent layperson, who possesses an 
     average knowledge of health and medicine, could reasonably 
     expect the absence of immediate medical attention to result 
     in a condition described in clause (i), (ii), or (iii) of 
     section 1867(e)(1)(A) of the Social Security Act.
       ``(B) Emergency services.--The term `emergency services' 
     means, with respect to an emergency medical condition--
       ``(i) a medical screening examination (as required under 
     section 1867 of the Social Security Act) that is within the 
     capability of the emergency department of a hospital, 
     including ancillary services routinely available to the 
     emergency department to evaluate such emergency medical 
     condition, and
       ``(ii) within the capabilities of the staff and facilities 
     available at the hospital, such further medical examination 
     and treatment as are required under section 1867 of such Act 
     to stabilize the patient.
       ``(C) Stabilize.--The term `to stabilize', with respect to 
     an emergency medical condition (as defined in subparagraph 
     (A)), has the meaning give in section 1867(e)(3) of the 
     Social Security Act (42 U.S.C. 1395dd(e)(3)).
       ``(c) Access to Pediatric Care.--
       ``(1) Pediatric care.--In the case of a person who has a 
     child who is a participant, beneficiary, or enrollee under a 
     group health plan, or health insurance coverage offered by a 
     health insurance issuer in the group or individual market, if 
     the plan or issuer requires or provides for the designation 
     of a participating primary care provider for the child, the 
     plan or issuer shall permit such person to designate a 
     physician (allopathic or osteopathic) who specializes in 
     pediatrics as the child's primary care provider if such 
     provider participates in the network of the plan or issuer.
       ``(2) Construction.--Nothing in paragraph (1) shall be 
     construed to waive any exclusions of coverage under the terms 
     and conditions of the plan or health insurance coverage with 
     respect to coverage of pediatric care.
       ``(d) Patient Access to Obstetrical and Gynecological 
     Care.--
       ``(1) General rights.--
       ``(A) Direct access.--A group health plan, or health 
     insurance issuer offering group or individual health 
     insurance coverage, described in paragraph (2) may not 
     require authorization or referral by the plan, issuer, or any 
     person (including a primary care provider described in 
     paragraph (2)(B))) in the case of a female participant, 
     beneficiary, or enrollee who seeks coverage for obstetrical 
     or gynecological care provided by a participating health care 
     professional who specializes in obstetrics or gynecology. 
     Such professional shall agree to otherwise adhere to such 
     plan's or issuer's policies and procedures, including 
     procedures regarding referrals and obtaining prior 
     authorization and providing services pursuant to a treatment 
     plan (if any) approved by the plan or issuer.
       ``(B) Obstetrical and gynecological care.--A group health 
     plan or health insurance issuer described in paragraph (2) 
     shall treat the provision of obstetrical and gynecological 
     care, and the ordering of related obstetrical and 
     gynecological items and services, pursuant to the direct 
     access described under subparagraph (A), by a participating 
     health care professional who specializes in obstetrics or 
     gynecology as the authorization of the primary care provider.
       ``(2) Application of paragraph.--A group health plan, or 
     health insurance issuer offering group or individual health 
     insurance coverage, described in this paragraph is a group 
     health plan or coverage that--
       ``(A) provides coverage for obstetric or gynecologic care; 
     and
       ``(B) requires the designation by a participant, 
     beneficiary, or enrollee of a participating primary care 
     provider.
       ``(3) Construction.--Nothing in paragraph (1) shall be 
     construed to--
       ``(A) waive any exclusions of coverage under the terms and 
     conditions of the plan or health insurance coverage with 
     respect to coverage of obstetrical or gynecological care; or
       ``(B) preclude the group health plan or health insurance 
     issuer involved from requiring that the obstetrical or 
     gynecological provider notify the primary care health care 
     professional or the plan or issuer of treatment decisions.''.
       (i) Section 2794 of the Public Health Service Act, as added 
     by section 1003 of this Act, is amended--
       (1) in subsection (c)(1)--
       (A) in subparagraph (A), by striking ``and'' at the end;
       (B) in subparagraph (B), by striking the period and 
     inserting ``; and''; and
       (C) by adding at the end the following:
       ``(C) in establishing centers (consistent with subsection 
     (d)) at academic or other nonprofit institutions to collect 
     medical reimbursement information from health insurance 
     issuers, to analyze and organize such information, and to 
     make such information available to such issuers, health care 
     providers, health researchers, health care policy makers, and 
     the general public.''; and
       (2) by adding at the end the following:
       ``(d) Medical Reimbursement Data Centers.--
       ``(1) Functions.--A center established under subsection 
     (c)(1)(C) shall--
       ``(A) develop fee schedules and other database tools that 
     fairly and accurately reflect market rates for medical 
     services and the geographic differences in those rates;
       ``(B) use the best available statistical methods and data 
     processing technology to develop such fee schedules and other 
     database tools;
       ``(C) regularly update such fee schedules and other 
     database tools to reflect changes in charges for medical 
     services;
       ``(D) make health care cost information readily available 
     to the public through an Internet website that allows 
     consumers to understand the amounts that health care 
     providers in their area charge for particular medical 
     services; and
       ``(E) regularly publish information concerning the 
     statistical methodologies used by the center to analyze 
     health charge data and make such data available to 
     researchers and policy makers.
       ``(2) Conflicts of interest.--A center established under 
     subsection (c)(1)(C) shall adopt by-laws that ensures that 
     the center (and all members of the governing board of the 
     center) is independent and free from all conflicts of 
     interest. Such by-laws shall ensure that the center is not 
     controlled or influenced by, and does not have any corporate 
     relation to, any individual or entity that may make or 
     receive payments for health care services based on the 
     center's analysis of health care costs.
       ``(3) Rule of construction.--Nothing in this subsection 
     shall be construed to permit a center established under 
     subsection (c)(1)(C) to compel health insurance issuers to 
     provide data to the center.''.

     SEC. 10102. AMENDMENTS TO SUBTITLE B.

       (a) Section 1102(a)(2)(B) of this Act is amended--
       (1) in the matter preceding clause (i), by striking ``group 
     health benefits plan'' and inserting ``group benefits plan 
     providing health benefits''; and

[[Page 32754]]

       (2) in clause (i)(I), by inserting ``or any agency or 
     instrumentality of any of the foregoing'' before the closed 
     parenthetical.
       (b) Section 1103(a) of this Act is amended--
       (1) in paragraph (1), by inserting ``, or small business 
     in,'' after ``residents of any''; and
       (2) by striking paragraph (2) and inserting the following:
       ``(2) Connecting to affordable coverage.--An Internet 
     website established under paragraph (1) shall, to the extent 
     practicable, provide ways for residents of, and small 
     businesses in, any State to receive information on at least 
     the following coverage options:
       ``(A) Health insurance coverage offered by health insurance 
     issuers, other than coverage that provides reimbursement only 
     for the treatment or mitigation of--
       ``(i) a single disease or condition; or
       ``(ii) an unreasonably limited set of diseases or 
     conditions (as determined by the Secretary).
       ``(B) Medicaid coverage under title XIX of the Social 
     Security Act.
       ``(C) Coverage under title XXI of the Social Security Act.
       ``(D) A State health benefits high risk pool, to the extent 
     that such high risk pool is offered in such State; and
       ``(E) Coverage under a high risk pool under section 1101.
       ``(F) Coverage within the small group market for small 
     businesses and their employees, including reinsurance for 
     early retirees under section 1102, tax credits available 
     under section 45R of the Internal Revenue Code of 1986 (as 
     added by section 1421), and other information specifically 
     for small businesses regarding affordable health care 
     options.''.

     SEC. 10103. AMENDMENTS TO SUBTITLE C.

       (a) Section 2701(a)(5) of the Public Health Service Act, as 
     added by section 1201(4) of this Act, is amended by inserting 
     ``(other than self-insured group health plans offered in such 
     market)'' after ``such market''.
       (b) Section 2708 of the Public Health Service Act, as added 
     by section 1201(4) of this Act, is amended by striking ``or 
     individual''.
       (c) Subpart I of part A of title XXVII of the Public Health 
     Service Act, as added by section 1201(4) of this Act, is 
     amended by inserting after section 2708, the following:

     ``SEC. 2709. COVERAGE FOR INDIVIDUALS PARTICIPATING IN 
                   APPROVED CLINICAL TRIALS.

       ``(a) Coverage.--
       ``(1) In general.--If a group health plan or a health 
     insurance issuer offering group or individual health 
     insurance coverage provides coverage to a qualified 
     individual, then such plan or issuer--
       ``(A) may not deny the individual participation in the 
     clinical trial referred to in subsection (b)(2);
       ``(B) subject to subsection (c), may not deny (or limit or 
     impose additional conditions on) the coverage of routine 
     patient costs for items and services furnished in connection 
     with participation in the trial; and
       ``(C) may not discriminate against the individual on the 
     basis of the individual's participation in such trial.
       ``(2) Routine patient costs.--
       ``(A) Inclusion.--For purposes of paragraph (1)(B), subject 
     to subparagraph (B), routine patient costs include all items 
     and services consistent with the coverage provided in the 
     plan (or coverage) that is typically covered for a qualified 
     individual who is not enrolled in a clinical trial.
       ``(B) Exclusion.--For purposes of paragraph (1)(B), routine 
     patient costs does not include--
       ``(i) the investigational item, device, or service, itself;
       ``(ii) items and services that are provided solely to 
     satisfy data collection and analysis needs and that are not 
     used in the direct clinical management of the patient; or
       ``(iii) a service that is clearly inconsistent with widely 
     accepted and established standards of care for a particular 
     diagnosis.
       ``(3) Use of in-network providers.--If one or more 
     participating providers is participating in a clinical trial, 
     nothing in paragraph (1) shall be construed as preventing a 
     plan or issuer from requiring that a qualified individual 
     participate in the trial through such a participating 
     provider if the provider will accept the individual as a 
     participant in the trial.
       ``(4) Use of out-of-network.--Notwithstanding paragraph 
     (3), paragraph (1) shall apply to a qualified individual 
     participating in an approved clinical trial that is conducted 
     outside the State in which the qualified individual resides.
       ``(b) Qualified Individual Defined.--For purposes of 
     subsection (a), the term `qualified individual' means an 
     individual who is a participant or beneficiary in a health 
     plan or with coverage described in subsection (a)(1) and who 
     meets the following conditions:
       ``(1) The individual is eligible to participate in an 
     approved clinical trial according to the trial protocol with 
     respect to treatment of cancer or other life-threatening 
     disease or condition.
       ``(2) Either--
       ``(A) the referring health care professional is a 
     participating health care provider and has concluded that the 
     individual's participation in such trial would be appropriate 
     based upon the individual meeting the conditions described in 
     paragraph (1); or
       ``(B) the participant or beneficiary provides medical and 
     scientific information establishing that the individual's 
     participation in such trial would be appropriate based upon 
     the individual meeting the conditions described in paragraph 
     (1).
       ``(c) Limitations on Coverage.--This section shall not be 
     construed to require a group health plan, or a health 
     insurance issuer offering group or individual health 
     insurance coverage, to provide benefits for routine patient 
     care services provided outside of the plan's (or coverage's) 
     health care provider network unless out-of-network benefits 
     are otherwise provided under the plan (or coverage).
       ``(d) Approved Clinical Trial Defined.--
       ``(1) In general.--In this section, the term `approved 
     clinical trial' means a phase I, phase II, phase III, or 
     phase IV clinical trial that is conducted in relation to the 
     prevention, detection, or treatment of cancer or other life-
     threatening disease or condition and is described in any of 
     the following subparagraphs:
       ``(A) Federally funded trials.--The study or investigation 
     is approved or funded (which may include funding through in-
     kind contributions) by one or more of the following:
       ``(i) The National Institutes of Health.
       ``(ii) The Centers for Disease Control and Prevention.
       ``(iii) The Agency for Health Care Research and Quality.
       ``(iv) The Centers for Medicare & Medicaid Services.
       ``(v) cooperative group or center of any of the entities 
     described in clauses (i) through (iv) or the Department of 
     Defense or the Department of Veterans Affairs.
       ``(vi) A qualified non-governmental research entity 
     identified in the guidelines issued by the National 
     Institutes of Health for center support grants.
       ``(vii) Any of the following if the conditions described in 
     paragraph (2) are met:

       ``(I) The Department of Veterans Affairs.
       ``(II) The Department of Defense.
       ``(III) The Department of Energy.

       ``(B) The study or investigation is conducted under an 
     investigational new drug application reviewed by the Food and 
     Drug Administration.
       ``(C) The study or investigation is a drug trial that is 
     exempt from having such an investigational new drug 
     application.
       ``(2) Conditions for departments.--The conditions described 
     in this paragraph, for a study or investigation conducted by 
     a Department, are that the study or investigation has been 
     reviewed and approved through a system of peer review that 
     the Secretary determines--
       ``(A) to be comparable to the system of peer review of 
     studies and investigations used by the National Institutes of 
     Health, and
       ``(B) assures unbiased review of the highest scientific 
     standards by qualified individuals who have no interest in 
     the outcome of the review.
       ``(e) Life-Threatening Condition Defined.--In this section, 
     the term `life-threatening condition' means any disease or 
     condition from which the likelihood of death is probable 
     unless the course of the disease or condition is interrupted.
       ``(f) Construction.--Nothing in this section shall be 
     construed to limit a plan's or issuer's coverage with respect 
     to clinical trials.
       ``(g) Application to FEHBP.--Notwithstanding any provision 
     of chapter 89 of title 5, United States Code, this section 
     shall apply to health plans offered under the program under 
     such chapter.
       ``(h) Preemption.--Notwithstanding any other provision of 
     this Act, nothing in this section shall preempt State laws 
     that require a clinical trials policy for State regulated 
     health insurance plans that is in addition to the policy 
     required under this section.''.
       (d) Section 1251(a) of this Act is amended--
       (1) in paragraph (2), by striking ``With'' and inserting 
     ``Except as provided in paragraph (3), with''; and
       (2) by adding at the end the following:
       ``(3) Application of certain provisions.--The provisions of 
     sections 2715 and 2718 of the Public Health Service Act (as 
     added by subtitle A) shall apply to grandfathered health 
     plans for plan years beginning on or after the date of 
     enactment of this Act.''.
       (e) Section 1253 of this Act is amended insert before the 
     period the following: ``, except that--
       ``(1) section 1251 shall take effect on the date of 
     enactment of this Act; and
       ``(2) the provisions of section 2704 of the Public Health 
     Service Act (as amended by section 1201), as they apply to 
     enrollees who are under 19 years of age, shall become 
     effective for plan years beginning on or after the date that 
     is 6 months after the date of enactment of this Act.''.
       (f) Subtitle C of title I of this Act is amended--
       (1) by redesignating section 1253 as section 1255; and
       (2) by inserting after section 1252, the following:

[[Page 32755]]



     ``SEC. 1253. ANNUAL REPORT ON SELF-INSURED PLANS.

       ``Not later than 1 year after the date of enactment of this 
     Act, and annually thereafter, the Secretary of Labor shall 
     prepare an aggregate annual report, using data collected from 
     the Annual Return/Report of Employee Benefit Plan (Department 
     of Labor Form 5500), that shall include general information 
     on self-insured group health plans (including plan type, 
     number of participants, benefits offered, funding 
     arrangements, and benefit arrangements) as well as data from 
     the financial filings of self-insured employers (including 
     information on assets, liabilities, contributions, 
     investments, and expenses). The Secretary shall submit such 
     reports to the appropriate committees of Congress.

     ``SEC. 1254. STUDY OF LARGE GROUP MARKET.

       ``(a) In General.--The Secretary of Health and Human 
     Services shall conduct a study of the fully-insured and self-
     insured group health plan markets to--
       ``(1) compare the characteristics of employers (including 
     industry, size, and other characteristics as determined 
     appropriate by the Secretary), health plan benefits, 
     financial solvency, capital reserve levels, and the risks of 
     becoming insolvent; and
       ``(2) determine the extent to which new insurance market 
     reforms are likely to cause adverse selection in the large 
     group market or to encourage small and midsize employers to 
     self-insure.
       ``(b) Collection of Information.--In conducting the study 
     under subsection (a), the Secretary, in coordination with the 
     Secretary of Labor, shall collect information and analyze--
       ``(1) the extent to which self-insured group health plans 
     can offer less costly coverage and, if so, whether lower 
     costs are due to more efficient plan administration and lower 
     overhead or to the denial of claims and the offering very 
     limited benefit packages;
       ``(2) claim denial rates, plan benefit fluctuations (to 
     evaluate the extent that plans scale back health benefits 
     during economic downturns), and the impact of the limited 
     recourse options on consumers; and
       ``(3) any potential conflict of interest as it relates to 
     the health care needs of self-insured enrollees and self-
     insured employer's financial contribution or profit margin, 
     and the impact of such conflict on administration of the 
     health plan.
       ``(c) Report.--Not later than 1 year after the date of 
     enactment of this Act, the Secretary shall submit to the 
     appropriate committees of Congress a report concerning the 
     results of the study conducted under subsection (a).''.

     SEC. 10104. AMENDMENTS TO SUBTITLE D.

       (a) Section 1301(a) of this Act is amended by striking 
     paragraph (2) and inserting the following:
       ``(2) Inclusion of co-op plans and multi-state qualified 
     health plans.--Any reference in this title to a qualified 
     health plan shall be deemed to include a qualified health 
     plan offered through the CO-OP program under section 1322, 
     and a multi-State plan under section 1334, unless 
     specifically provided for otherwise.
       ``(3) Treatment of qualified direct primary care medical 
     home plans.--The Secretary of Health and Human Services shall 
     permit a qualified health plan to provide coverage through a 
     qualified direct primary care medical home plan that meets 
     criteria established by the Secretary, so long as the 
     qualified health plan meets all requirements that are 
     otherwise applicable and the services covered by the medical 
     home plan are coordinated with the entity offering the 
     qualified health plan.
       ``(4) Variation based on rating area.--A qualified health 
     plan, including a multi-State qualified health plan, may as 
     appropriate vary premiums by rating area (as defined in 
     section 2701(a)(2) of the Public Health Service Act).''.
       (b) Section 1302 of this Act is amended--
       (1) in subsection (d)(2)(B), by striking ``may issue'' and 
     inserting ``shall issue''; and
       (2) by adding at the end the following:
       ``(g) Payments to Federally-Qualified Health Centers.--If 
     any item or service covered by a qualified health plan is 
     provided by a Federally-qualified health center (as defined 
     in section 1905(l)(2)(B) of the Social Security Act (42 
     U.S.C. 1396d(l)(2)(B)) to an enrollee of the plan, the 
     offeror of the plan shall pay to the center for the item or 
     service an amount that is not less than the amount of payment 
     that would have been paid to the center under section 
     1902(bb) of such Act (42 U.S.C. 1396a(bb)) for such item or 
     service.''.
       (c) Section 1303 of this Act is amended to read as follows:

     ``SEC. 1303. SPECIAL RULES.

       ``(a) State Opt-Out of Abortion Coverage.--
       ``(1) In general.--A State may elect to prohibit abortion 
     coverage in qualified health plans offered through an 
     Exchange in such State if such State enacts a law to provide 
     for such prohibition.
       ``(2) Termination of opt out.--A State may repeal a law 
     described in paragraph (1) and provide for the offering of 
     such services through the Exchange.
       ``(b) Special Rules Relating to Coverage of Abortion 
     Services.--
       ``(1) Voluntary choice of coverage of abortion services.--
       ``(A) In general.--Notwithstanding any other provision of 
     this title (or any amendment made by this title)--
       ``(i) nothing in this title (or any amendment made by this 
     title), shall be construed to require a qualified health plan 
     to provide coverage of services described in subparagraph 
     (B)(i) or (B)(ii) as part of its essential health benefits 
     for any plan year; and
       ``(ii) subject to subsection (a), the issuer of a qualified 
     health plan shall determine whether or not the plan provides 
     coverage of services described in subparagraph (B)(i) or 
     (B)(ii) as part of such benefits for the plan year.
       ``(B) Abortion services.--
       ``(i) Abortions for which public funding is prohibited.--
     The services described in this clause are abortions for which 
     the expenditure of Federal funds appropriated for the 
     Department of Health and Human Services is not permitted, 
     based on the law as in effect as of the date that is 6 months 
     before the beginning of the plan year involved.
       ``(ii) Abortions for which public funding is allowed.--The 
     services described in this clause are abortions for which the 
     expenditure of Federal funds appropriated for the Department 
     of Health and Human Services is permitted, based on the law 
     as in effect as of the date that is 6 months before the 
     beginning of the plan year involved.
       ``(2) Prohibition on the use of federal funds.--
       ``(A) In general.--If a qualified health plan provides 
     coverage of services described in paragraph (1)(B)(i), the 
     issuer of the plan shall not use any amount attributable to 
     any of the following for purposes of paying for such 
     services:
       ``(i) The credit under section 36B of the Internal Revenue 
     Code of 1986 (and the amount (if any) of the advance payment 
     of the credit under section 1412 of the Patient Protection 
     and Affordable Care Act).
       ``(ii) Any cost-sharing reduction under section 1402 of 
     thePatient Protection and Affordable Care Act (and the amount 
     (if any) of the advance payment of the reduction under 
     section 1412 of the Patient Protection and Affordable Care 
     Act).
       ``(B) Establishment of allocation accounts.--In the case of 
     a plan to which subparagraph (A) applies, the issuer of the 
     plan shall--
       ``(i) collect from each enrollee in the plan (without 
     regard to the enrollee's age, sex, or family status) a 
     separate payment for each of the following:

       ``(I) an amount equal to the portion of the premium to be 
     paid directly by the enrollee for coverage under the plan of 
     services other than services described in paragraph (1)(B)(i) 
     (after reduction for credits and cost-sharing reductions 
     described in subparagraph (A)); and
       ``(II) an amount equal to the actuarial value of the 
     coverage of services described in paragraph (1)(B)(i), and

       ``(ii) shall deposit all such separate payments into 
     separate allocation accounts as provided in subparagraph (C).
     In the case of an enrollee whose premium for coverage under 
     the plan is paid through employee payroll deposit, the 
     separate payments required under this subparagraph shall each 
     be paid by a separate deposit.
       ``(C) Segregation of funds.--
       ``(i) In general.--The issuer of a plan to which 
     subparagraph (A) applies shall establish allocation accounts 
     described in clause (ii) for enrollees receiving amounts 
     described in subparagraph (A).
       ``(ii) Allocation accounts.--The issuer of a plan to which 
     subparagraph (A) applies shall deposit--

       ``(I) all payments described in subparagraph (B)(i)(I) into 
     a separate account that consists solely of such payments and 
     that is used exclusively to pay for services other than 
     services described in paragraph (1)(B)(i); and
       ``(II) all payments described in subparagraph (B)(i)(II) 
     into a separate account that consists solely of such payments 
     and that is used exclusively to pay for services described in 
     paragraph (1)(B)(i).

       ``(D) Actuarial value.--
       ``(i) In general.--The issuer of a qualified health plan 
     shall estimate the basic per enrollee, per month cost, 
     determined on an average actuarial basis, for including 
     coverage under the qualified health plan of the services 
     described in paragraph (1)(B)(i).
       ``(ii) Considerations.--In making such estimate, the 
     issuer--

       ``(I) may take into account the impact on overall costs of 
     the inclusion of such coverage, but may not take into account 
     any cost reduction estimated to result from such services, 
     including prenatal care, delivery, or postnatal care;
       ``(II) shall estimate such costs as if such coverage were 
     included for the entire population covered; and
       ``(III) may not estimate such a cost at less than $1 per 
     enrollee, per month.

       ``(E) Ensuring compliance with segregation requirements.--
       ``(i) In general.--Subject to clause (ii), State health 
     insurance commissioners shall ensure that health plans comply 
     with the segregation requirements in this subsection through 
     the segregation of plan funds in accordance with applicable 
     provisions of generally accepted accounting requirements,

[[Page 32756]]

     circulars on funds management of the Office of Management and 
     Budget, and guidance on accounting of the Government 
     Accountability Office.
       ``(ii) Clarification.--Nothing in clause (i) shall prohibit 
     the right of an individual or health plan to appeal such 
     action in courts of competent jurisdiction.
       ``(3) Rules relating to notice.--
       ``(A) Notice.--A qualified health plan that provides for 
     coverage of the services described in paragraph (1)(B)(i) 
     shall provide a notice to enrollees, only as part of the 
     summary of benefits and coverage explanation, at the time of 
     enrollment, of such coverage.
       ``(B) Rules relating to payments.--The notice described in 
     subparagraph (A), any advertising used by the issuer with 
     respect to the plan, any information provided by the 
     Exchange, and any other information specified by the 
     Secretary shall provide information only with respect to the 
     total amount of the combined payments for services described 
     in paragraph (1)(B)(i) and other services covered by the 
     plan.
       ``(4) No discrimination on basis of provision of 
     abortion.--No qualified health plan offered through an 
     Exchange may discriminate against any individual health care 
     provider or health care facility because of its unwillingness 
     to provide, pay for, provide coverage of, or refer for 
     abortions
       ``(c) Application of State and Federal Laws Regarding 
     Abortion.--
       ``(1) No preemption of state laws regarding abortion.--
     Nothing in this Act shall be construed to preempt or 
     otherwise have any effect on State laws regarding the 
     prohibition of (or requirement of) coverage, funding, or 
     procedural requirements on abortions, including parental 
     notification or consent for the performance of an abortion on 
     a minor.
       ``(2) No effect on federal laws regarding abortion.--
       ``(A) In general.--Nothing in this Act shall be construed 
     to have any effect on Federal laws regarding--
       ``(i) conscience protection;
       ``(ii) willingness or refusal to provide abortion; and
       ``(iii) discrimination on the basis of the willingness or 
     refusal to provide, pay for, cover, or refer for abortion or 
     to provide or participate in training to provide abortion.
       ``(3) No effect on federal civil rights law.--Nothing in 
     this subsection shall alter the rights and obligations of 
     employees and employers under title VII of the Civil Rights 
     Act of 1964.
       ``(d) Application of Emergency Services Laws.--Nothing in 
     this Act shall be construed to relieve any health care 
     provider from providing emergency services as required by 
     State or Federal law, including section 1867 of the Social 
     Security Act (popularly known as `EMTALA').''.
       (d) Section 1304 of this Act is amended by adding at the 
     end the following:
       ``(e) Educated Health Care Consumers.--The term `educated 
     health care consumer' means an individual who is 
     knowledgeable about the health care system, and has 
     background or experience in making informed decisions 
     regarding health, medical, and scientific matters.''.
       (e) Section 1311(d) of this Act is amended--
       (1) in paragraph (3)(B), by striking clause (ii) and 
     inserting the following:
       ``(ii) State must assume cost.--A State shall make 
     payments--

       ``(I) to an individual enrolled in a qualified health plan 
     offered in such State; or
       ``(II) on behalf of an individual described in subclause 
     (I) directly to the qualified health plan in which such 
     individual is enrolled;

     to defray the cost of any additional benefits described in 
     clause (i).''; and
       (2) in paragraph (6)(A), by inserting ``educated'' before 
     ``health care''.
       (f) Section 1311(e) of this Act is amended--
       (1) in paragraph (2), by striking ``may'' in the second 
     sentence and inserting ``shall''; and
       (2) by adding at the end the following:
       ``(3) Transparency in coverage.--
       ``(A) In general.--The Exchange shall require health plans 
     seeking certification as qualified health plans to submit to 
     the Exchange, the Secretary, the State insurance 
     commissioner, and make available to the public, accurate and 
     timely disclosure of the following information:
       ``(i) Claims payment policies and practices.
       ``(ii) Periodic financial disclosures.
       ``(iii) Data on enrollment.
       ``(iv) Data on disenrollment.
       ``(v) Data on the number of claims that are denied.
       ``(vi) Data on rating practices.
       ``(vii) Information on cost-sharing and payments with 
     respect to any out-of-network coverage.
       ``(viii) Information on enrollee and participant rights 
     under this title.
       ``(ix) Other information as determined appropriate by the 
     Secretary.
       ``(B) Use of plain language.--The information required to 
     be submitted under subparagraph (A) shall be provided in 
     plain language. The term `plain language' means language that 
     the intended audience, including individuals with limited 
     English proficiency, can readily understand and use because 
     that language is concise, well-organized, and follows other 
     best practices of plain language writing. The Secretary and 
     the Secretary of Labor shall jointly develop and issue 
     guidance on best practices of plain language writing.
       ``(C) Cost sharing transparency.--The Exchange shall 
     require health plans seeking certification as qualified 
     health plans to permit individuals to learn the amount of 
     cost-sharing (including deductibles, copayments, and 
     coinsurance) under the individual's plan or coverage that the 
     individual would be responsible for paying with respect to 
     the furnishing of a specific item or service by a 
     participating provider in a timely manner upon the request of 
     the individual. At a minimum, such information shall be made 
     available to such individual through an Internet website and 
     such other means for individuals without access to the 
     Internet.
       ``(D) Group health plans.--The Secretary of Labor shall 
     update and harmonize the Secretary's rules concerning the 
     accurate and timely disclosure to participants by group 
     health plans of plan disclosure, plan terms and conditions, 
     and periodic financial disclosure with the standards 
     established by the Secretary under subparagraph (A).''.
       (g) Section 1311(g)(1) of this Act is amended--
       (1) in subparagraph (C), by striking ``; and'' and 
     inserting a semicolon;
       (2) in subparagraph (D), by striking the period and 
     inserting ``; and''; and
       (3) by adding at the end the following:
       ``(E) the implementation of activities to reduce health and 
     health care disparities, including through the use of 
     language services, community outreach, and cultural 
     competency trainings.''.
       (h) Section 1311(i)(2)((B) of this Act is amended by 
     striking ``small business development centers'' and inserting 
     ``resource partners of the Small Business Administration''.
       (i) Section 1312 of this Act is amended--
       (1) in subsection (a)(1), by inserting ``and for which such 
     individual is eligible'' before the period;
       (2) in subsection (e)--
       (A) in paragraph (1), by inserting ``and employers'' after 
     ``enroll individuals''; and
       (B) by striking the flush sentence at the end; and
       (3) in subsection (f)(1)(A)(ii), by striking the 
     parenthetical.
       (j)(1) Subparagraph (B) of section 1313(a)(6) of this Act 
     is hereby deemed null, void, and of no effect.
       (2) Section 3730(e) of title 31, United States Code, is 
     amended by striking paragraph (4) and inserting the 
     following:
       ``(4)(A) The court shall dismiss an action or claim under 
     this section, unless opposed by the Government, if 
     substantially the same allegations or transactions as alleged 
     in the action or claim were publicly disclosed--
       ``(i) in a Federal criminal, civil, or administrative 
     hearing in which the Government or its agent is a party;
       ``(ii) in a congressional, Government Accountability 
     Office, or other Federal report, hearing, audit, or 
     investigation; or
       ``(iii) from the news media,
     unless the action is brought by the Attorney General or the 
     person bringing the action is an original source of the 
     information.
       ``(B) For purposes of this paragraph, ``original source'' 
     means an individual who either (i) prior to a public 
     disclosure under subsection (e)(4)(a), has voluntarily 
     disclosed to the Government the information on which 
     allegations or transactions in a claim are based, or (2) who 
     has knowledge that is independent of and materially adds to 
     the publicly disclosed allegations or transactions, and who 
     has voluntarily provided the information to the Government 
     before filing an action under this section.''.
       (k) Section 1313(b) of this Act is amended--
       (1) in paragraph (3), by striking ``and'' at the end;
       (2) by redesignating paragraph (4) as paragraph (5); and
       (3) by inserting after paragraph (3) the following:
       ``(4) a survey of the cost and affordability of health care 
     insurance provided under the Exchanges for owners and 
     employees of small business concerns (as defined under 
     section 3 of the Small Business Act (15 U.S.C. 632)), 
     including data on enrollees in Exchanges and individuals 
     purchasing health insurance coverage outside of Exchanges; 
     and''.
       (l) Section 1322(b) of this Act is amended--
       (1) by redesignating paragraph (3) as paragraph (4); and
       (2) by inserting after paragraph (2), the following:
       ``(3) Repayment of loans and grants.--Not later than July 
     1, 2013, and prior to awarding loans and grants under the CO-
     OP program, the Secretary shall promulgate regulations with 
     respect to the repayment of such loans and grants in a manner 
     that is consistent with State solvency regulations and other 
     similar State laws that may apply. In promulgating such 
     regulations, the Secretary shall provide that such loans 
     shall be repaid within 5 years and such grants shall be 
     repaid within 15 years, taking into consideration any 
     appropriate State reserve requirements, solvency regulations, 
     and requisite surplus note arrangements that must be 
     constructed in a State to provide for such

[[Page 32757]]

     repayment prior to awarding such loans and grants.''.
       (m) Part III of subtitle D of title I of this Act is 
     amended by striking section 1323.
       (n) Section 1324(a) of this Act is amended by striking ``, 
     a community health'' and all that follows through ``1333(b)'' 
     and inserting ``, or a multi-State qualified health plan 
     under section 1334''.
       (o) Section 1331 of this Act is amended--
       (1) in subsection (d)(3)(A)(i), by striking ``85'' and 
     inserting ``95''; and
       (2) in subsection (e)(1)(B), by inserting before the 
     semicolon the following: ``, or, in the case of an alien 
     lawfully present in the United States, whose income is not 
     greater than 133 percent of the poverty line for the size of 
     the family involved but who is not eligible for the Medicaid 
     program under title XIX of the Social Security Act by reason 
     of such alien status''.
       (p) Section 1333 of this Act is amended by striking 
     subsection (b).
       (q) Part IV of subtitle D of title I of this Act is amended 
     by adding at the end the following:

     ``SEC. 1334. MULTI-STATE PLANS.

       ``(a) Oversight by the Office of Personnel Management.--
       ``(1) In general.--The Director of the Office of Personnel 
     Management (referred to in this section as the `Director') 
     shall enter into contracts with health insurance issuers 
     (which may include a group of health insurance issuers 
     affiliated either by common ownership and control or by the 
     common use of a nationally licensed service mark), without 
     regard to section 5 of title 41, United States Code, or other 
     statutes requiring competitive bidding, to offer at least 2 
     multi-State qualified health plans through each Exchange in 
     each State. Such plans shall provide individual, or in the 
     case of small employers, group coverage.
       ``(2) Terms.--Each contract entered into under paragraph 
     (1) shall be for a uniform term of at least 1 year, but may 
     be made automatically renewable from term to term in the 
     absence of notice of termination by either party. In entering 
     into such contracts, the Director shall ensure that health 
     benefits coverage is provided in accordance with the types of 
     coverage provided for under section 2701(a)(1)(A)(i) of the 
     Public Health Service Act.
       ``(3) Non-profit entities.--In entering into contracts 
     under paragraph (1), the Director shall ensure that at least 
     one contract is entered into with a non-profit entity.
       ``(4) Administration.--The Director shall implement this 
     subsection in a manner similar to the manner in which the 
     Director implements the contracting provisions with respect 
     to carriers under the Federal employees health benefit 
     program under chapter 89 of title 5, United States Code, 
     including (through negotiating with each multi-state plan)--
       ``(A) a medical loss ratio;
       ``(B) a profit margin;
       ``(C) the premiums to be charged; and
       ``(D) such other terms and conditions of coverage as are in 
     the interests of enrollees in such plans.
       ``(5) Authority to protect consumers.--The Director may 
     prohibit the offering of any multi-State health plan that 
     does not meet the terms and conditions defined by the 
     Director with respect to the elements described in 
     subparagraphs (A) through (D) of paragraph (4).
       ``(6) Assured availability of varied coverage.--In entering 
     into contracts under this subsection, the Director shall 
     ensure that with respect to multi-State qualified health 
     plans offered in an Exchange, there is at least one such plan 
     that does not provide coverage of services described in 
     section 1303(b)(1)(B)(i).
       ``(7) Withdrawal.--Approval of a contract under this 
     subsection may be withdrawn by the Director only after notice 
     and opportunity for hearing to the issuer concerned without 
     regard to subchapter II of chapter 5 and chapter 7 of title 
     5, United States Code.
       ``(b) Eligibility.--A health insurance issuer shall be 
     eligible to enter into a contract under subsection (a)(1) if 
     such issuer--
       ``(1) agrees to offer a multi-State qualified health plan 
     that meets the requirements of subsection (c) in each 
     Exchange in each State;
       ``(2) is licensed in each State and is subject to all 
     requirements of State law not inconsistent with this section, 
     including the standards and requirements that a State imposes 
     that do not prevent the application of a requirement of part 
     A of title XXVII of the Public Health Service Act or a 
     requirement of this title;
       ``(3) otherwise complies with the minimum standards 
     prescribed for carriers offering health benefits plans under 
     section 8902(e) of title 5, United States Code, to the extent 
     that such standards do not conflict with a provision of this 
     title; and
       ``(4) meets such other requirements as determined 
     appropriate by the Director, in consultation with the 
     Secretary.
       ``(c) Requirements for Multi-State Qualified Health Plan.--
       ``(1) In general.--A multi-State qualified health plan 
     meets the requirements of this subsection if, in the 
     determination of the Director--
       ``(A) the plan offers a benefits package that is uniform in 
     each State and consists of the essential benefits described 
     in section 1302;
       ``(B) the plan meets all requirements of this title with 
     respect to a qualified health plan, including requirements 
     relating to the offering of the bronze, silver, and gold 
     levels of coverage and catastrophic coverage in each State 
     Exchange;
       ``(C) except as provided in paragraph (5), the issuer 
     provides for determinations of premiums for coverage under 
     the plan on the basis of the rating requirements of part A of 
     title XXVII of the Public Health Service Act; and
       ``(D) the issuer offers the plan in all geographic regions, 
     and in all States that have adopted adjusted community rating 
     before the date of enactment of this Act.
       ``(2) States may offer additional benefits.--Nothing in 
     paragraph (1)(A) shall preclude a State from requiring that 
     benefits in addition to the essential health benefits 
     required under such paragraph be provided to enrollees of a 
     multi-State qualified health plan offered in such State.
       ``(3) Credits.--
       ``(A) In general.--An individual enrolled in a multi-State 
     qualified health plan under this section shall be eligible 
     for credits under section 36B of the Internal Revenue Code of 
     1986 and cost sharing assistance under section 1402 in the 
     same manner as an individual who is enrolled in a qualified 
     health plan.
       ``(B) No additional federal cost.--A requirement by a State 
     under paragraph (2) that benefits in addition to the 
     essential health benefits required under paragraph (1)(A) be 
     provided to enrollees of a multi-State qualified health plan 
     shall not affect the amount of a premium tax credit provided 
     under section 36B of the Internal Revenue Code of 1986 with 
     respect to such plan.
       ``(4) State must assume cost.--A State shall make 
     payments--
       ``(A) to an individual enrolled in a multi-State qualified 
     health plan offered in such State; or
       ``(B) on behalf of an individual described in subparagraph 
     (A) directly to the multi-State qualified health plan in 
     which such individual is enrolled;
     to defray the cost of any additional benefits described in 
     paragraph (2).
       ``(5) Application of certain state rating requirements.--
     With respect to a multi-State qualified health plan that is 
     offered in a State with age rating requirements that are 
     lower than 3:1, the State may require that Exchanges 
     operating in such State only permit the offering of such 
     multi-State qualified health plans if such plans comply with 
     the State's more protective age rating requirements.
       ``(d) Plans Deemed to Be Certified.--A multi-State 
     qualified health plan that is offered under a contract under 
     subsection (a) shall be deemed to be certified by an Exchange 
     for purposes of section 1311(d)(4)(A).
       ``(e) Phase-in.--Notwithstanding paragraphs (1) and (2) of 
     subsection (b), the Director shall enter into a contract with 
     a health insurance issuer for the offering of a multi-State 
     qualified health plan under subsection (a) if--
       ``(1) with respect to the first year for which the issuer 
     offers such plan, such issuer offers the plan in at least 60 
     percent of the States;
       ``(2) with respect to the second such year, such issuer 
     offers the plan in at least 70 percent of the States;
       ``(3) with respect to the third such year, such issuer 
     offers the plan in at least 85 percent of the States; and
       ``(4) with respect to each subsequent year, such issuer 
     offers the plan in all States.
       ``(f) Applicability.--The requirements under chapter 89 of 
     title 5, United States Code, applicable to health benefits 
     plans under such chapter shall apply to multi-State qualified 
     health plans provided for under this section to the extent 
     that such requirements do not conflict with a provision of 
     this title.
       ``(g) Continued Support for FEHBP.--
       ``(1) Maintenance of effort.--Nothing in this section shall 
     be construed to permit the Director to allocate fewer 
     financial or personnel resources to the functions of the 
     Office of Personnel Management related to the administration 
     of the Federal Employees Health Benefit Program under chapter 
     89 of title 5, United States Code.
       ``(2) Separate risk pool.--Enrollees in multi-State 
     qualified health plans under this section shall be treated as 
     a separate risk pool apart from enrollees in the Federal 
     Employees Health Benefit Program under chapter 89 of title 5, 
     United States Code.
       ``(3) Authority to establish separate entities.--The 
     Director may establish such separate units or offices within 
     the Office of Personnel Management as the Director determines 
     to be appropriate to ensure that the administration of multi-
     State qualified health plans under this section does not 
     interfere with the effective administration of the Federal 
     Employees Health Benefit Program under chapter 89 of title 5, 
     United States Code.
       ``(4) Effective oversight.--The Director may appoint such 
     additional personnel as may be necessary to enable the 
     Director to carry out activities under this section.
       ``(5) Assurance of separate program.--In carrying out this 
     section, the Director shall ensure that the program under 
     this section

[[Page 32758]]

     is separate from the Federal Employees Health Benefit Program 
     under chapter 89 of title 5, United States Code. Premiums 
     paid for coverage under a multi-State qualified health plan 
     under this section shall not be considered to be Federal 
     funds for any purposes.
       ``(6) FEHBP plans not required to participate.--Nothing in 
     this section shall require that a carrier offering coverage 
     under the Federal Employees Health Benefit Program under 
     chapter 89 of title 5, United States Code, also offer a 
     multi-State qualified health plan under this section.
       ``(h) Advisory Board.--The Director shall establish an 
     advisory board to provide recommendations on the activities 
     described in this section. A significant percentage of the 
     members of such board shall be comprised of enrollees in a 
     multi-State qualified health plan, or representatives of such 
     enrollees.
       ``(i) Authorization of Appropriations.--There is authorized 
     to be appropriated, such sums as may be necessary to carry 
     out this section.''.
       (r) Section 1341 of this Act is amended--
       (1) in the section heading, by striking ``and small group 
     markets'' and inserting ``market'';
       (2) in subsection (b)(2)(B), by striking ``paragraph 
     (1)(A)'' and inserting ``paragraph (1)(B)''; and
       (3) in subsection (c)(1)(A), by striking ``and small group 
     markets'' and inserting ``market''.

     SEC. 10105. AMENDMENTS TO SUBTITLE E.

       (a) Section 36B(b)(3)(A)(ii) of the Internal Revenue Code 
     of 1986, as added by section 1401(a) of this Act, is amended 
     by striking ``is in excess of'' and inserting ``equals or 
     exceeds''.
       (b) Section 36B(c)(1)(A) of the Internal Revenue Code of 
     1986, as added by section 1401(a) of this Act, is amended by 
     inserting ``equals or'' before ``exceeds''.
       (c) Section 36B(c)(2)(C)(iv) of the Internal Revenue Code 
     of 1986, as added by section 1401(a) of this Act, is amended 
     by striking ``subsection (b)(3)(A)(ii)'' and inserting 
     ``subsection (b)(3)(A)(iii)''.
       (d) Section 1401(d) of this Act is amended by adding at the 
     end the following:
       ``(3) Section 6211(b)(4)(A) of the Internal Revenue Code of 
     1986 is amended by inserting `36B,' after `36A,'.''.
       (e)(1) Subparagraph (B) of section 45R(d)(3) of the 
     Internal Revenue Code of 1986, as added by section 1421(a) of 
     this Act, is amended to read as follows:
       ``(B) Dollar amount.--For purposes of paragraph (1)(B) and 
     subsection (c)(2)--
       ``(i) 2010, 2011, 2012, and 2013.--The dollar amount in 
     effect under this paragraph for taxable years beginning in 
     2010, 2011, 2012, or 2013 is $25,000.
       ``(ii) Subsequent years.--In the case of a taxable year 
     beginning in a calendar year after 2013, the dollar amount in 
     effect under this paragraph shall be equal to $25,000, 
     multiplied by the cost-of-living adjustment under section 
     1(f)(3) for the calendar year, determined by substituting 
     `calendar year 2012' for `calendar year 1992' in subparagraph 
     (B) thereof.''.
       (2) Subsection (g) of section 45R of the Internal Revenue 
     Code of 1986, as added by section 1421(a) of this Act, is 
     amended by striking ``2011'' both places it appears and 
     inserting ``2010, 2011''.
       (3) Section 280C(h) of the Internal Revenue Code of 1986, 
     as added by section 1421(d)(1) of this Act, is amended by 
     striking ``2011'' and inserting ``2010, 2011''.
       (4) Section 1421(f) of this Act is amended by striking 
     ``2010'' both places it appears and inserting ``2009''.
       (5) The amendments made by this subsection shall take 
     effect as if included in the enactment of section 1421 of 
     this Act.
       (f) Part I of subtitle E of title I of this Act is amended 
     by adding at the end of subpart B, the following:

     ``SEC. 1416. STUDY OF GEOGRAPHIC VARIATION IN APPLICATION OF 
                   FPL.

       ``(a) In General.--The Secretary shall conduct a study to 
     examine the feasibility and implication of adjusting the 
     application of the Federal poverty level under this subtitle 
     (and the amendments made by this subtitle) for different 
     geographic areas so as to reflect the variations in cost-of-
     living among different areas within the United States. If the 
     Secretary determines that an adjustment is feasible, the 
     study should include a methodology to make such an 
     adjustment. Not later than January 1, 2013, the Secretary 
     shall submit to Congress a report on such study and shall 
     include such recommendations as the Secretary determines 
     appropriate.
       ``(b) Inclusion of Territories.--
       ``(1) In general.--The Secretary shall ensure that the 
     study under subsection (a) covers the territories of the 
     United States and that special attention is paid to the 
     disparity that exists among poverty levels and the cost of 
     living in such territories and to the impact of such 
     disparity on efforts to expand health coverage and ensure 
     health care.
       ``(2) Territories defined.--In this subsection, the term 
     `territories of the United States' includes the Commonwealth 
     of Puerto Rico, the United States Virgin Islands, Guam, the 
     Northern Mariana Islands, and any other territory or 
     possession of the United States.''.

     SEC. 10106. AMENDMENTS TO SUBTITLE F.

       (a) Section 1501(a)(2) of this Act is amended to read as 
     follows:
       ``(2) Effects on the national economy and interstate 
     commerce.--The effects described in this paragraph are the 
     following:
       ``(A) The requirement regulates activity that is commercial 
     and economic in nature: economic and financial decisions 
     about how and when health care is paid for, and when health 
     insurance is purchased. In the absence of the requirement, 
     some individuals would make an economic and financial 
     decision to forego health insurance coverage and attempt to 
     self-insure, which increases financial risks to households 
     and medical providers.
       ``(B) Health insurance and health care services are a 
     significant part of the national economy. National health 
     spending is projected to increase from $2,500,000,000,000, or 
     17.6 percent of the economy, in 2009 to $4,700,000,000,000 in 
     2019. Private health insurance spending is projected to be 
     $854,000,000,000 in 2009, and pays for medical supplies, 
     drugs, and equipment that are shipped in interstate commerce. 
     Since most health insurance is sold by national or regional 
     health insurance companies, health insurance is sold in 
     interstate commerce and claims payments flow through 
     interstate commerce.
       ``(C) The requirement, together with the other provisions 
     of this Act, will add millions of new consumers to the health 
     insurance market, increasing the supply of, and demand for, 
     health care services, and will increase the number and share 
     of Americans who are insured.
       ``(D) The requirement achieves near-universal coverage by 
     building upon and strengthening the private employer-based 
     health insurance system, which covers 176,000,000 Americans 
     nationwide. In Massachusetts, a similar requirement has 
     strengthened private employer-based coverage: despite the 
     economic downturn, the number of workers offered employer-
     based coverage has actually increased.
       ``(E) The economy loses up to $207,000,000,000 a year 
     because of the poorer health and shorter lifespan of the 
     uninsured. By significantly reducing the number of the 
     uninsured, the requirement, together with the other 
     provisions of this Act, will significantly reduce this 
     economic cost.
       ``(F) The cost of providing uncompensated care to the 
     uninsured was $43,000,000,000 in 2008. To pay for this cost, 
     health care providers pass on the cost to private insurers, 
     which pass on the cost to families. This cost-shifting 
     increases family premiums by on average over $1,000 a year. 
     By significantly reducing the number of the uninsured, the 
     requirement, together with the other provisions of this Act, 
     will lower health insurance premiums.
       ``(G) 62 percent of all personal bankruptcies are caused in 
     part by medical expenses. By significantly increasing health 
     insurance coverage, the requirement, together with the other 
     provisions of this Act, will improve financial security for 
     families.
       ``(H) Under the Employee Retirement Income Security Act of 
     1974 (29 U.S.C. 1001 et seq.), the Public Health Service Act 
     (42 U.S.C. 201 et seq.), and this Act, the Federal Government 
     has a significant role in regulating health insurance. The 
     requirement is an essential part of this larger regulation of 
     economic activity, and the absence of the requirement would 
     undercut Federal regulation of the health insurance market.
       ``(I) Under sections 2704 and 2705 of the Public Health 
     Service Act (as added by section 1201 of this Act), if there 
     were no requirement, many individuals would wait to purchase 
     health insurance until they needed care. By significantly 
     increasing health insurance coverage, the requirement, 
     together with the other provisions of this Act, will minimize 
     this adverse selection and broaden the health insurance risk 
     pool to include healthy individuals, which will lower health 
     insurance premiums. The requirement is essential to creating 
     effective health insurance markets in which improved health 
     insurance products that are guaranteed issue and do not 
     exclude coverage of pre-existing conditions can be sold.
       ``(J) Administrative costs for private health insurance, 
     which were $90,000,000,000 in 2006, are 26 to 30 percent of 
     premiums in the current individual and small group markets. 
     By significantly increasing health insurance coverage and the 
     size of purchasing pools, which will increase economies of 
     scale, the requirement, together with the other provisions of 
     this Act, will significantly reduce administrative costs and 
     lower health insurance premiums. The requirement is essential 
     to creating effective health insurance markets that do not 
     require underwriting and eliminate its associated 
     administrative costs.''.
       (b)(1) Section 5000A(b)(1) of the Internal Revenue Code of 
     1986, as added by section 1501(b) of this Act, is amended to 
     read as follows:
       ``(1) In general.--If a taxpayer who is an applicable 
     individual, or an applicable individual for whom the taxpayer 
     is liable under paragraph (3), fails to meet the requirement 
     of subsection (a) for 1 or more months, then, except as 
     provided in subsection (e), there is hereby imposed on the 
     taxpayer a penalty with respect to such failures in the 
     amount determined under subsection (c).''.

[[Page 32759]]

       (2) Paragraphs (1) and (2) of section 5000A(c) of the 
     Internal Revenue Code of 1986, as so added, are amended to 
     read as follows:
       ``(1) In general.--The amount of the penalty imposed by 
     this section on any taxpayer for any taxable year with 
     respect to failures described in subsection (b)(1) shall be 
     equal to the lesser of--
       ``(A) the sum of the monthly penalty amounts determined 
     under paragraph (2) for months in the taxable year during 
     which 1 or more such failures occurred, or
       ``(B) an amount equal to the national average premium for 
     qualified health plans which have a bronze level of coverage, 
     provide coverage for the applicable family size involved, and 
     are offered through Exchanges for plan years beginning in the 
     calendar year with or within which the taxable year ends.
       ``(2) Monthly penalty amounts.--For purposes of paragraph 
     (1)(A), the monthly penalty amount with respect to any 
     taxpayer for any month during which any failure described in 
     subsection (b)(1) occurred is an amount equal to \1/12\ of 
     the greater of the following amounts:
       ``(A) Flat dollar amount.--An amount equal to the lesser 
     of--
       ``(i) the sum of the applicable dollar amounts for all 
     individuals with respect to whom such failure occurred during 
     such month, or
       ``(ii) 300 percent of the applicable dollar amount 
     (determined without regard to paragraph (3)(C)) for the 
     calendar year with or within which the taxable year ends.
       ``(B) Percentage of income.--An amount equal to the 
     following percentage of the taxpayer's household income for 
     the taxable year:
       ``(i) 0.5 percent for taxable years beginning in 2014.
       ``(ii) 1.0 percent for taxable years beginning in 2015.
       ``(iii) 2.0 percent for taxable years beginning after 
     2015.''.
       (3) Section 5000A(c)(3) of the Internal Revenue Code of 
     1986, as added by section 1501(b) of this Act, is amended by 
     striking ``$350'' and inserting ``$495''.
       (c) Section 5000A(d)(2)(A) of the Internal Revenue Code of 
     1986, as added by section 1501(b) of this Act, is amended to 
     read as follows:
       ``(A) Religious conscience exemption.--Such term shall not 
     include any individual for any month if such individual has 
     in effect an exemption under section 1311(d)(4)(H) of the 
     Patient Protection and Affordable Care Act which certifies 
     that such individual is--
       ``(i) a member of a recognized religious sect or division 
     thereof which is described in section 1402(g)(1), and
       ``(ii) an adherent of established tenets or teachings of 
     such sect or division as described in such section.''.
       (d) Section 5000A(e)(1)(C) of the Internal Revenue Code of 
     1986, as added by section 1501(b) of this Act, is amended to 
     read as follows:
       ``(C) Special rules for individuals related to employees.--
     For purposes of subparagraph (B)(i), if an applicable 
     individual is eligible for minimum essential coverage through 
     an employer by reason of a relationship to an employee, the 
     determination under subparagraph (A) shall be made by 
     reference to required contribution of the employee.''.
       (e) Section 4980H(b) of the Internal Revenue Code of 1986, 
     as added by section 1513(a) of this Act, is amended to read 
     as follows:
       ``(b) Large Employers With Waiting Periods Exceeding 60 
     Days.--
       ``(1) In general.--In the case of any applicable large 
     employer which requires an extended waiting period to enroll 
     in any minimum essential coverage under an employer-sponsored 
     plan (as defined in section 5000A(f)(2)), there is hereby 
     imposed on the employer an assessable payment of $600 for 
     each full-time employee of the employer to whom the extended 
     waiting period applies.
       ``(2) Extended waiting period.--The term `extended waiting 
     period' means any waiting period (as defined in section 
     2701(b)(4) of the Public Health Service Act) which exceeds 60 
     days.''.
       (f)(1) Subparagraph (A) of section 4980H(d)(4) of the 
     Internal Revenue Code of 1986, as added by section 1513(a) of 
     this Act, is amended by inserting ``, with respect to any 
     month,'' after ``means''.
       (2) Section 4980H(d)(2) of the Internal Revenue Code of 
     1986, as added by section 1513(a) of this Act, is amended by 
     adding at the end the following:
       ``(D) Application to construction industry employers.--In 
     the case of any employer the substantial annual gross 
     receipts of which are attributable to the construction 
     industry--
       ``(i) subparagraph (A) shall be applied by substituting 
     `who employed an average of at least 5 full-time employees on 
     business days during the preceding calendar year and whose 
     annual payroll expenses exceed $250,000 for such preceding 
     calendar year' for `who employed an average of at least 50 
     full-time employees on business days during the preceding 
     calendar year', and
       ``(ii) subparagraph (B) shall be applied by substituting 
     `5' for `50'.''.
       (3) The amendment made by paragraph (2) shall apply to 
     months beginning after December 31, 2013.
       (g) Section 6056(b) of the Internal Revenue Code of 1986, 
     as added by section 1514(a) of the Act, is amended by adding 
     at the end the following new flush sentence:
     ``The Secretary shall have the authority to review the 
     accuracy of the information provided under this subsection, 
     including the applicable large employer's share under 
     paragraph (2)(C)(iv).''.

     SEC. 10107. AMENDMENTS TO SUBTITLE G.

       (a) Section 1562 of this Act is amended, in the amendment 
     made by subsection (a)(2)(B)(iii), by striking ``subpart 1'' 
     and inserting ``subparts I and II''; and
       (b) Subtitle G of title I of this Act is amended--
       (1) by redesignating section 1562 (as amended) as section 
     1563; and
       (2) by inserting after section 1561 the following:

     ``SEC. 1562. GAO STUDY REGARDING THE RATE OF DENIAL OF 
                   COVERAGE AND ENROLLMENT BY HEALTH INSURANCE 
                   ISSUERS AND GROUP HEALTH PLANS.

       ``(a) In General.--The Comptroller General of the United 
     States (referred to in this section as the `Comptroller 
     General') shall conduct a study of the incidence of denials 
     of coverage for medical services and denials of applications 
     to enroll in health insurance plans, as described in 
     subsection (b), by group health plans and health insurance 
     issuers.
       ``(b) Data.--
       ``(1) In general.--In conducting the study described in 
     subsection (a), the Comptroller General shall consider 
     samples of data concerning the following:
       ``(A)(i) denials of coverage for medical services to a plan 
     enrollees, by the types of services for which such coverage 
     was denied; and
       ``(ii) the reasons such coverage was denied; and
       ``(B)(i) incidents in which group health plans and health 
     insurance issuers deny the application of an individual to 
     enroll in a health insurance plan offered by such group 
     health plan or issuer; and
       ``(ii) the reasons such applications are denied.
       ``(2) Scope of data.--
       ``(A) Favorably resolved disputes.--The data that the 
     Comptroller General considers under paragraph (1) shall 
     include data concerning denials of coverage for medical 
     services and denials of applications for enrollment in a plan 
     by a group health plan or health insurance issuer, where such 
     group health plan or health insurance issuer later approves 
     such coverage or application.
       ``(B) All health plans.--The study under this section shall 
     consider data from varied group health plans and health 
     insurance plans offered by health insurance issuers, 
     including qualified health plans and health plans that are 
     not qualified health plans.
       ``(c) Report.--Not later than one year after the date of 
     enactment of this Act, the Comptroller General shall submit 
     to the Secretaries of Health and Human Services and Labor a 
     report describing the results of the study conducted under 
     this section.
       ``(d) Publication of Report.--The Secretaries of Health and 
     Human Services and Labor shall make the report described in 
     subsection (c) available to the public on an Internet 
     website.

     ``SEC. 1563. SMALL BUSINESS PROCUREMENT.

       ``Part 19 of the Federal Acquisition Regulation, section 15 
     of the Small Business Act (15 U.S.C. 644), and any other 
     applicable laws or regulations establishing procurement 
     requirements relating to small business concerns (as defined 
     in section 3 of the Small Business Act (15 U.S.C. 632)) may 
     not be waived with respect to any contract awarded under any 
     program or other authority under this Act or an amendment 
     made by this Act.''.

     SEC. 10108. FREE CHOICE VOUCHERS.

       (a) In General.--An offering employer shall provide free 
     choice vouchers to each qualified employee of such employer.
       (b) Offering Employer.--For purposes of this section, the 
     term ``offering employer'' means any employer who--
       (1) offers minimum essential coverage to its employees 
     consisting of coverage through an eligible employer-sponsored 
     plan; and
       (2) pays any portion of the costs of such plan.
       (c) Qualified Employee.--For purposes of this section--
       (1) In general.--The term ``qualified employee'' means, 
     with respect to any plan year of an offering employer, any 
     employee--
       (A) whose required contribution (as determined under 
     section 5000A(e)(1)(B)) for minimum essential coverage 
     through an eligible employer-sponsored plan--
       (i) exceeds 8 percent of such employee's household income 
     for the taxable year described in section 1412(b)(1)(B) which 
     ends with or within in the plan year; and
       (ii) does not exceed 9.8 percent of such employee's 
     household income for such taxable year;
       (B) whose household income for such taxable year is not 
     greater than 400 percent of the poverty line for a family of 
     the size involved; and
       (C) who does not participate in a health plan offered by 
     the offering employer.
       (2) Indexing.--In the case of any calendar year beginning 
     after 2014, the Secretary shall

[[Page 32760]]

     adjust the 8 percent under paragraph (1)(A)(i) and 9.8 
     percent under paragraph (1)(A)(ii) for the calendar year to 
     reflect the rate of premium growth between the preceding 
     calendar year and 2013 over the rate of income growth for 
     such period.
       (d) Free Choice Voucher.--
       (1) Amount.--
       (A) In general.--The amount of any free choice voucher 
     provided under subsection (a) shall be equal to the monthly 
     portion of the cost of the eligible employer-sponsored plan 
     which would have been paid by the employer if the employee 
     were covered under the plan with respect to which the 
     employer pays the largest portion of the cost of the plan. 
     Such amount shall be equal to the amount the employer would 
     pay for an employee with self-only coverage unless such 
     employee elects family coverage (in which case such amount 
     shall be the amount the employer would pay for family 
     coverage).
       (B) Determination of cost.--The cost of any health plan 
     shall be determined under the rules similar to the rules of 
     section 2204 of the Public Health Service Act, except that 
     such amount shall be adjusted for age and category of 
     enrollment in accordance with regulations established by the 
     Secretary.
       (2) Use of vouchers.--An Exchange shall credit the amount 
     of any free choice voucher provided under subsection (a) to 
     the monthly premium of any qualified health plan in the 
     Exchange in which the qualified employee is enrolled and the 
     offering employer shall pay any amounts so credited to the 
     Exchange.
       (3) Payment of excess amounts.--If the amount of the free 
     choice voucher exceeds the amount of the premium of the 
     qualified health plan in which the qualified employee is 
     enrolled for such month, such excess shall be paid to the 
     employee.
       (e) Other Definitions.--Any term used in this section which 
     is also used in section 5000A of the Internal Revenue Code of 
     1986 shall have the meaning given such term under such 
     section 5000A.
       (f) Exclusion From Income for Employee.--
       (1) In general.--Part III of subchapter B of chapter 1 of 
     the Internal Revenue Code of 1986 is amended by inserting 
     after section 139C the following new section:

     ``SEC. 139D. FREE CHOICE VOUCHERS.

       ``Gross income shall not include the amount of any free 
     choice voucher provided by an employer under section 10108 of 
     the Patient Protection and Affordable Care Act to the extent 
     that the amount of such voucher does not exceed the amount 
     paid for a qualified health plan (as defined in section 1301 
     of such Act) by the taxpayer.''.
       (2) Clerical amendment.--The table of sections for part III 
     of subchapter B of chapter 1 of such Code is amended by 
     inserting after the item relating to section 139C the 
     following new item:

``Sec. 139D. Free choice vouchers.''.
       (3) Effective date.--The amendments made by this subsection 
     shall apply to vouchers provided after December 31, 2013.
       (g) Deduction Allowed to Employer.--
       (1) In general.--Section 162(a) of the Internal Revenue 
     Code of 1986 is amended by adding at the end the following 
     new sentence: ``For purposes of paragraph (1), the amount of 
     a free choice voucher provided under section 10108 of the 
     Patient Protection and Affordable Care Act shall be treated 
     as an amount for compensation for personal services actually 
     rendered.''.
       (2) Effective date.--The amendments made by this subsection 
     shall apply to vouchers provided after December 31, 2013.
       (h) Voucher Taken Into Account in Determining Premium 
     Credit.--
       (1) In general.--Subsection (c)(2) of section 36B of the 
     Internal Revenue Code of 1986, as added by section 1401, is 
     amended by adding at the end the following new subparagraph:
       ``(D) Exception for individual receiving free choice 
     vouchers.--The term `coverage month' shall not include any 
     month in which such individual has a free choice voucher 
     provided under section 10108 of the Patient Protection and 
     Affordable Care Act.''.
       (2) Effective date.--The amendment made by this subsection 
     shall apply to taxable years beginning after December 31, 
     2013.
       (i) Coordination With Employer Responsibilities.--
       (1) Shared responsibility penalty.--
       (A) In general.--Subsection (c) of section 4980H of the 
     Internal Revenue Code of 1986, as added by section 1513, is 
     amended by adding at the end the following new paragraph:
       ``(3) Special rules for employers providing free choice 
     vouchers.--No assessable payment shall be imposed under 
     paragraph (1) for any month with respect to any employee to 
     whom the employer provides a free choice voucher under 
     section 10108 of the Patient Protection and Affordable Care 
     Act for such month.''.
       (B) Effective date.--The amendment made by this paragraph 
     shall apply to months beginning after December 31, 2013.
       (2) Notification requirement.--Section 18B(a)(3) of the 
     Fair Labor Standards Act of 1938, as added by section 1512, 
     is amended--
       (A) by inserting ``and the employer does not offer a free 
     choice voucher'' after ``Exchange''; and
       (B) by striking ``will lose'' and inserting ``may lose''.
       (j) Employer Reporting.--
       (1) In general.--Subsection (a) of section 6056 of the 
     Internal Revenue Code of 1986, as added by section 1514, is 
     amended by inserting ``and every offering employer'' before 
     ``shall''.
       (2) Offering employers.--Subsection (f) of section 6056 of 
     such Code, as added by section 1514, is amended to read as 
     follows:
       ``(f) Definitions.--For purposes of this section--
       ``(1) Offering employer.--
       ``(A) In general.--The term `offering employer' means any 
     offering employer (as defined in section 10108(b) of the 
     Patient Protection and Affordable Care Act) if the required 
     contribution (within the meaning of section 
     5000A(e)(1)(B)(i)) of any employee exceeds 8 percent of the 
     wages (as defined in section 3121(a)) paid to such employee 
     by such employer.
       ``(B) Indexing.--In the case of any calendar year beginning 
     after 2014, the 8 percent under subparagraph (A) shall be 
     adjusted for the calendar year to reflect the rate of premium 
     growth between the preceding calendar year and 2013 over the 
     rate of income growth for such period.
       ``(2) Other definitions.--Any term used in this section 
     which is also used in section 4980H shall have the meaning 
     given such term by section 4980H.''.
       (3) Conforming amendments.--
       (A) The heading of section 6056 of such Code, as added by 
     section 1514, is amended by striking ``large'' and inserting 
     ``certain''.
       (B) Section 6056(b)(2)(C) of such Code is amended--
       (i) by inserting ``in the case of an applicable large 
     employer,'' before ``the length'' in clause (i);
       (ii) by striking ``and'' at the end of clause (iii);
       (iii) by striking ``applicable large employer'' in clause 
     (iv) and inserting ``employer'';
       (iv) by inserting ``and'' at the end of clause (iv); and
       (v) by inserting at the end the following new clause:
       ``(v) in the case of an offering employer, the option for 
     which the employer pays the largest portion of the cost of 
     the plan and the portion of the cost paid by the employer in 
     each of the enrollment categories under such option,''.
       (C) Section 6056(d)(2) of such Code is amended by inserting 
     ``or offering employer'' after ``applicable large employer''.
       (D) Section 6056(e) of such Code is amended by inserting 
     ``or offering employer'' after ``applicable large employer''.
       (E) Section 6724(d)(1)(B)(xxv) of such Code, as added by 
     section 1514, is amended by striking ``large'' and inserting 
     ``certain''.
       (F) Section 6724(d)(2)(HH) of such Code, as added by 
     section 1514, is amended by striking ``large'' and inserting 
     ``certain''.
       (G) The table of sections for subpart D of part III of 
     subchapter A of chapter 1 of such Code, as amended by section 
     1514, is amended by striking ``Large employers'' in the item 
     relating to section 6056 and inserting ``Certain employers''.
       (4) Effective date.--The amendments made by this subsection 
     shall apply to periods beginning after December 31, 2013.

     SEC. 10109. DEVELOPMENT OF STANDARDS FOR FINANCIAL AND 
                   ADMINISTRATIVE TRANSACTIONS.

       (a) Additional Transaction Standards and Operating Rules.--
       (1) Development of additional transaction standards and 
     operating rules.--Section 1173(a) of the Social Security Act 
     (42 U.S.C. 1320d-2(a)), as amended by section 1104(b)(2), is 
     amended--
       (A) in paragraph (1)(B), by inserting before the period the 
     following: ``, and subject to the requirements under 
     paragraph (5)''; and
       (B) by adding at the end the following new paragraph:
       ``(5) Consideration of standardization of activities and 
     items.--
       ``(A) In general.--For purposes of carrying out paragraph 
     (1)(B), the Secretary shall solicit, not later than January 
     1, 2012, and not less than every 3 years thereafter, input 
     from entities described in subparagraph (B) on--
       ``(i) whether there could be greater uniformity in 
     financial and administrative activities and items, as 
     determined appropriate by the Secretary; and
       ``(ii) whether such activities should be considered 
     financial and administrative transactions (as described in 
     paragraph (1)(B)) for which the adoption of standards and 
     operating rules would improve the operation of the health 
     care system and reduce administrative costs.
       ``(B) Solicitation of input.--For purposes of subparagraph 
     (A), the Secretary shall seek input from--
       ``(i) the National Committee on Vital and Health 
     Statistics, the Health Information Technology Policy 
     Committee, and the Health Information Technology Standards 
     Committee; and
       ``(ii) standard setting organizations and stakeholders, as 
     determined appropriate by the Secretary.''.
       (b) Activities and Items for Initial Consideration.--For 
     purposes of section 1173(a)(5) of the Social Security Act, as 
     added by subsection (a), the Secretary of Health and Human 
     Services (in this section referred

[[Page 32761]]

     to as the ``Secretary'') shall, not later than January 1, 
     2012, seek input on activities and items relating to the 
     following areas:
       (1) Whether the application process, including the use of a 
     uniform application form, for enrollment of health care 
     providers by health plans could be made electronic and 
     standardized.
       (2) Whether standards and operating rules described in 
     section 1173 of the Social Security Act should apply to the 
     health care transactions of automobile insurance, worker's 
     compensation, and other programs or persons not described in 
     section 1172(a) of such Act (42 U.S.C. 1320d-1(a)).
       (3) Whether standardized forms could apply to financial 
     audits required by health plans, Federal and State agencies 
     (including State auditors, the Office of the Inspector 
     General of the Department of Health and Human Services, and 
     the Centers for Medicare & Medicaid Services), and other 
     relevant entities as determined appropriate by the Secretary.
       (4) Whether there could be greater transparency and 
     consistency of methodologies and processes used to establish 
     claim edits used by health plans (as described in section 
     1171(5) of the Social Security Act (42 U.S.C. 1320d(5))).
       (5) Whether health plans should be required to publish 
     their timeliness of payment rules.
       (c) ICD Coding Crosswalks.--
       (1) ICD-9 to icd-10 crosswalk.--The Secretary shall task 
     the ICD-9-CM Coordination and Maintenance Committee to 
     convene a meeting, not later than January 1, 2011, to receive 
     input from appropriate stakeholders (including health plans, 
     health care providers, and clinicians) regarding the 
     crosswalk between the Ninth and Tenth Revisions of the 
     International Classification of Diseases (ICD-9 and ICD-10, 
     respectively) that is posted on the website of the Centers 
     for Medicare & Medicaid Services, and make recommendations 
     about appropriate revisions to such crosswalk.
       (2) Revision of crosswalk.--For purposes of the crosswalk 
     described in paragraph (1), the Secretary shall make 
     appropriate revisions and post any such revised crosswalk on 
     the website of the Centers for Medicare & Medicaid Services.
       (3) Use of revised crosswalk.--For purposes of paragraph 
     (2), any revised crosswalk shall be treated as a code set for 
     which a standard has been adopted by the Secretary for 
     purposes of section 1173(c)(1)(B) of the Social Security Act 
     (42 U.S.C. 1320d-2(c)(1)(B)).
       (4) Subsequent crosswalks.--For subsequent revisions of the 
     International Classification of Diseases that are adopted by 
     the Secretary as a standard code set under section 1173(c) of 
     the Social Security Act (42 U.S.C. 1320d-2(c)), the Secretary 
     shall, after consultation with the appropriate stakeholders, 
     post on the website of the Centers for Medicare & Medicaid 
     Services a crosswalk between the previous and subsequent 
     version of the International Classification of Diseases not 
     later than the date of implementation of such subsequent 
     revision.

              Subtitle B--Provisions Relating to Title II

                       PART I--MEDICAID AND CHIP

     SEC. 10201. AMENDMENTS TO THE SOCIAL SECURITY ACT AND TITLE 
                   II OF THIS ACT.

       (a)(1) Section 1902(a)(10)(A)(i)(IX) of the Social Security 
     Act (42 U.S.C. 1396a(a)(10)(A)(i)(IX)), as added by section 
     2004(a), is amended to read as follows:

       ``(IX) who--

       ``(aa) are under 26 years of age;
       ``(bb) are not described in or enrolled under any of 
     subclauses (I) through (VII) of this clause or are described 
     in any of such subclauses but have income that exceeds the 
     level of income applicable under the State plan for 
     eligibility to enroll for medical assistance under such 
     subclause;
       ``(cc) were in foster care under the responsibility of the 
     State on the date of attaining 18 years of age or such higher 
     age as the State has elected under section 475(8)(B)(iii); 
     and
       ``(dd) were enrolled in the State plan under this title or 
     under a waiver of the plan while in such foster care;''.
       (2) Section 1902(a)(10) of the Social Security Act (42 
     U.S.C. 1396a(a)(10), as amended by section 2001(a)(5)(A), is 
     amended in the matter following subparagraph (G), by striking 
     ``and (XV)'' and inserting ``(XV)'', and by inserting ``and 
     (XVI) if an individual is described in subclause (IX) of 
     subparagraph (A)(i) and is also described in subclause (VIII) 
     of that subparagraph, the medical assistance shall be made 
     available to the individual through subclause (IX) instead of 
     through subclause (VIII)'' before the semicolon.
       (3) Section 2004(d) of this Act is amended by striking 
     ``2019'' and inserting ``2014''.
       (b) Section 1902(k)(2) of the Social Security Act (42 
     U.S.C. 1396a(k)(2)), as added by section 2001(a)(4)(A), is 
     amended by striking ``January 1, 2011'' and inserting ``April 
     1, 2010''.
       (c) Section 1905 of the Social Security Act (42 U.S.C. 
     1396d), as amended by sections 2001(a)(3), 2001(a)(5)(C), 
     2006, and 4107(a)(2), is amended--
       (1) in subsection (a), in the matter preceding paragraph 
     (1), by inserting in clause (xiv), ``or 
     1902(a)(10)(A)(i)(IX)'' before the comma;
       (2) in subsection (b), in the first sentence, by inserting 
     ``, (z),'' before ``and (aa)'';
       (3) in subsection (y)--
       (A) in paragraph (1)(B)(ii)(II), in the first sentence, by 
     inserting ``includes inpatient hospital services,'' after 
     ``100 percent of the poverty line, that''; and
       (B) in paragraph (2)(A), by striking ``on the date of 
     enactment of the Patient Protection and Affordable Care Act'' 
     and inserting ``as of December 1, 2009'';
       (4) by inserting after subsection (y) the following:
       ``(z) Equitable Support for Certain States.--
       ``(1)(A) During the period that begins on January 1, 2014, 
     and ends on September 30, 2019, notwithstanding subsection 
     (b), the Federal medical assistance percentage otherwise 
     determined under subsection (b) with respect to a fiscal year 
     occurring during that period shall be increased by 2.2 
     percentage points for any State described in subparagraph (B) 
     for amounts expended for medical assistance for individuals 
     who are not newly eligible (as defined in subsection (y)(2)) 
     individuals described in subclause (VIII) of section 
     1902(a)(10)(A)(i).
       ``(B) For purposes of subparagraph (A), a State described 
     in this subparagraph is a State that--
       ``(i) is an expansion State described in subsection 
     (y)(1)(B)(ii)(II);
       ``(ii) the Secretary determines will not receive any 
     payments under this title on the basis of an increased 
     Federal medical assistance percentage under subsection (y) 
     for expenditures for medical assistance for newly eligible 
     individuals (as so defined); and
       ``(iii) has not been approved by the Secretary to divert a 
     portion of the DSH allotment for a State to the costs of 
     providing medical assistance or other health benefits 
     coverage under a waiver that is in effect on July 2009.
       ``(2)(A) During the period that begins on January 1, 2014, 
     and ends on December 31, 2016, notwithstanding subsection 
     (b), the Federal medical assistance percentage otherwise 
     determined under subsection (b) with respect to all or any 
     portion of a fiscal year occurring during that period shall 
     be increased by .5 percentage point for a State described in 
     subparagraph (B) for amounts expended for medical assistance 
     under the State plan under this title or under a waiver of 
     that plan during that period.
       ``(B) For purposes of subparagraph (A), a State described 
     in this subparagraph is a State that--
       ``(i) is described in clauses (i) and (ii) of paragraph 
     (1)(B); and
       ``(ii) is the State with the highest percentage of its 
     population insured during 2008, based on the Current 
     Population Survey.
       ``(3) Notwithstanding subsection (b) and paragraphs (1) and 
     (2) of this subsection, the Federal medical assistance 
     percentage otherwise determined under subsection (b) with 
     respect to all or any portion of a fiscal year that begins on 
     or after January 1, 2017, for the State of Nebraska, with 
     respect to amounts expended for newly eligible individuals 
     described in subclause (VIII) of section 1902(a)(10)(A)(i), 
     shall be determined as provided for under subsection 
     (y)(1)(A) (notwithstanding the period provided for in such 
     paragraph).
       ``(4) The increase in the Federal medical assistance 
     percentage for a State under paragraphs (1), (2), or (3) 
     shall apply only for purposes of this title and shall not 
     apply with respect to--
       ``(A) disproportionate share hospital payments described in 
     section 1923;
       ``(B) payments under title IV;
       ``(C) payments under title XXI; and
       ``(D) payments under this title that are based on the 
     enhanced FMAP described in section 2105(b).'';
       (5) in subsection (aa), is amended by striking ``without 
     regard to this subsection and subsection (y)'' and inserting 
     ``without regard to this subsection, subsection (y), 
     subsection (z), and section 10202 of the Patient Protection 
     and Affordable Care Act'' each place it appears;
       (6) by adding after subsection (bb), the following:
       ``(cc) Requirement for Certain States.--Notwithstanding 
     subsections (y), (z), and (aa), in the case of a State that 
     requires political subdivisions within the State to 
     contribute toward the non-Federal share of expenditures 
     required under the State plan under section 1902(a)(2), the 
     State shall not be eligible for an increase in its Federal 
     medical assistance percentage under such subsections if it 
     requires that political subdivisions pay a greater percentage 
     of the non-Federal share of such expenditures, or a greater 
     percentage of the non-Federal share of payments under section 
     1923, than the respective percentages that would have been 
     required by the State under the State plan under this title, 
     State law, or both, as in effect on December 31, 2009, and 
     without regard to any such increase. Voluntary contributions 
     by a political subdivision to the non-Federal share of 
     expenditures under the State plan under this title or to the 
     non-Federal share of payments under section 1923, shall not 
     be considered to be required contributions for purposes of 
     this subsection. The treatment of voluntary contributions, 
     and the treatment of contributions required by a State under 
     the State plan under this

[[Page 32762]]

     title, or State law, as provided by this subsection, shall 
     also apply to the increases in the Federal medical assistance 
     percentage under section 5001 of the American Recovery and 
     Reinvestment Act of 2009.''.
       (d) Section 1108(g)(4)(B) of the Social Security Act (42 
     U.S.C. 1308(g)(4)(B)), as added by section 2005(b), is 
     amended by striking ``income eligibility level in effect for 
     that population under title XIX or under a waiver'' and 
     inserting ``the highest income eligibility level in effect 
     for parents under the commonwealth's or territory's State 
     plan under title XIX or under a waiver of the plan''.
       (e)(1) Section 1923(f) of the Social Security Act (42 
     U.S.C. 1396r-4(f)), as amended by section 2551, is amended--
       (A) in paragraph (6)--
       (i) by striking the paragraph heading and inserting the 
     following: ``Allotment adjustments''; and
       (ii) in subparagraph (B), by adding at the end the 
     following:
       ``(iii) Allotment for 2d, 3rd, and 4th quarter of fiscal 
     year 2012, fiscal year 2013, and succeeding fiscal years.--
     Notwithstanding the table set forth in paragraph (2) or 
     paragraph (7):

       ``(I) 2d, 3rd, and 4th quarter of fiscal year 2012.--The 
     DSH allotment for Hawaii for the 2d, 3rd, and 4th quarters of 
     fiscal year 2012 shall be $7,500,000.
       ``(II) Treatment as a low-dsh state for fiscal year 2013 
     and succeeding fiscal years.--With respect to fiscal year 
     2013, and each fiscal year thereafter, the DSH allotment for 
     Hawaii shall be increased in the same manner as allotments 
     for low DSH States are increased for such fiscal year under 
     clause (iii) of paragraph (5)(B).
       ``(III) Certain hospital payments.--The Secretary may not 
     impose a limitation on the total amount of payments made to 
     hospitals under the QUEST section 1115 Demonstration Project 
     except to the extent that such limitation is necessary to 
     ensure that a hospital does not receive payments in excess of 
     the amounts described in subsection (g), or as necessary to 
     ensure that such payments under the waiver and such payments 
     pursuant to the allotment provided in this clause do not, in 
     the aggregate in any year, exceed the amount that the 
     Secretary determines is equal to the Federal medical 
     assistance percentage component attributable to 
     disproportionate share hospital payment adjustments for such 
     year that is reflected in the budget neutrality provision of 
     the QUEST Demonstration Project.''; and

       (B) in paragraph (7)--
       (i) in subparagraph (A), in the matter preceding clause 
     (i), by striking ``subparagraph (E)'' and inserting 
     ``subparagraphs (E) and (G)'';
       (ii) in subparagraph (B)--
       (I) in clause (i), by striking subclauses (I) and (II), and 
     inserting the following:

       ``(I) if the State is a low DSH State described in 
     paragraph (5)(B) and has spent not more than 99.90 percent of 
     the DSH allotments for the State on average for the period of 
     fiscal years 2004 through 2008, as of September 30, 2009, the 
     applicable percentage is equal to 25 percent;
       ``(II) if the State is a low DSH State described in 
     paragraph (5)(B) and has spent more than 99.90 percent of the 
     DSH allotments for the State on average for the period of 
     fiscal years 2004 through 2008, as of September 30, 2009, the 
     applicable percentage is equal to 17.5 percent;
       ``(III) if the State is not a low DSH State described in 
     paragraph (5)(B) and has spent not more than 99.90 percent of 
     the DSH allotments for the State on average for the period of 
     fiscal years 2004 through 2008, as of September 30, 2009, the 
     applicable percentage is equal to 50 percent; and
       ``(IV) if the State is not a low DSH State described in 
     paragraph (5)(B) and has spent more than 99.90 percent of the 
     DSH allotments for the State on average for the period of 
     fiscal years 2004 through 2008, as of September 30, 2009, the 
     applicable percentage is equal to 35 percent.'';

       (II) in clause (ii), by striking subclauses (I) and (II), 
     and inserting the following:

       ``(I) if the State is a low DSH State described in 
     paragraph (5)(B) and has spent not more than 99.90 percent of 
     the DSH allotments for the State on average for the period of 
     fiscal years 2004 through 2008, as of September 30, 2009, the 
     applicable percentage is equal to the product of the 
     percentage reduction in uncovered individuals for the fiscal 
     year from the preceding fiscal year and 27.5 percent;
       ``(II) if the State is a low DSH State described in 
     paragraph (5)(B) and has spent more than 99.90 percent of the 
     DSH allotments for the State on average for the period of 
     fiscal years 2004 through 2008, as of September 30, 2009, the 
     applicable percentage is equal to the product of the 
     percentage reduction in uncovered individuals for the fiscal 
     year from the preceding fiscal year and 20 percent;
       ``(III) if the State is not a low DSH State described in 
     paragraph (5)(B) and has spent not more than 99.90 percent of 
     the DSH allotments for the State on average for the period of 
     fiscal years 2004 through 2008, as of September 30, 2009, the 
     applicable percentage is equal to the product of the 
     percentage reduction in uncovered individuals for the fiscal 
     year from the preceding fiscal year and 55 percent; and
       ``(IV) if the State is not a low DSH State described in 
     paragraph (5)(B) and has spent more than 99.90 percent of the 
     DSH allotments for the State on average for the period of 
     fiscal years 2004 through 2008, as of September 30, 2009, the 
     applicable percentage is equal to the product of the 
     percentage reduction in uncovered individuals for the fiscal 
     year from the preceding fiscal year and 40 percent.'';

       (III) in subparagraph (E), by striking ``35 percent'' and 
     inserting ``50 percent''; and
       (IV) by adding at the end the following:
       ``(G) Nonapplication.--The preceding provisions of this 
     paragraph shall not apply to the DSH allotment determined for 
     the State of Hawaii for a fiscal year under paragraph (6).''.
       (f) Section 2551 of this Act is amended by striking 
     subsection (b).
       (g) Section 2105(d)(3)(B) of the Social Security Act (42 
     U.S.C. 1397ee(d)(3)(B)), as added by section 2101(b)(1), is 
     amended by adding at the end the following: ``For purposes of 
     eligibility for premium assistance for the purchase of a 
     qualified health plan under section 36B of the Internal 
     Revenue Code of 1986 and reduced cost-sharing under section 
     1402 of the Patient Protection and Affordable Care Act, 
     children described in the preceding sentence shall be deemed 
     to be ineligible for coverage under the State child health 
     plan.''.
       (h) Clause (i) of subparagraph (C) of section 513(b)(2) of 
     the Social Security Act, as added by section 2953 of this 
     Act, is amended to read as follows:
       ``(i) Healthy relationships, including marriage and family 
     interactions.''.
       (i) Section 1115 of the Social Security Act (42 U.S.C. 
     1315) is amended by inserting after subsection (c) the 
     following:
       ``(d)(1) An application or renewal of any experimental, 
     pilot, or demonstration project undertaken under subsection 
     (a) to promote the objectives of title XIX or XXI in a State 
     that would result in an impact on eligibility, enrollment, 
     benefits, cost-sharing, or financing with respect to a State 
     program under title XIX or XXI (in this subsection referred 
     to as a `demonstration project') shall be considered by the 
     Secretary in accordance with the regulations required to be 
     promulgated under paragraph (2).
       ``(2) Not later than 180 days after the date of enactment 
     of this subsection, the Secretary shall promulgate 
     regulations relating to applications for, and renewals of, a 
     demonstration project that provide for--
       ``(A) a process for public notice and comment at the State 
     level, including public hearings, sufficient to ensure a 
     meaningful level of public input;
       ``(B) requirements relating to--
       ``(i) the goals of the program to be implemented or renewed 
     under the demonstration project;
       ``(ii) the expected State and Federal costs and coverage 
     projections of the demonstration project; and
       ``(iii) the specific plans of the State to ensure that the 
     demonstration project will be in compliance with title XIX or 
     XXI;
       ``(C) a process for providing public notice and comment 
     after the application is received by the Secretary, that is 
     sufficient to ensure a meaningful level of public input;
       ``(D) a process for the submission to the Secretary of 
     periodic reports by the State concerning the implementation 
     of the demonstration project; and
       ``(E) a process for the periodic evaluation by the 
     Secretary of the demonstration project.
       ``(3) The Secretary shall annually report to Congress 
     concerning actions taken by the Secretary with respect to 
     applications for demonstration projects under this 
     section.''.
       (j) Subtitle F of title III of this Act is amended by 
     adding at the end the following:

     ``SEC. 3512. GAO STUDY AND REPORT ON CAUSES OF ACTION.

       ``(a) Study.--
       ``(1) In general.--The Comptroller General of the United 
     States shall conduct a study of whether the development, 
     recognition, or implementation of any guideline or other 
     standards under a provision described in paragraph (2) would 
     result in the establishment of a new cause of action or 
     claim.
       ``(2) Provisions described.--The provisions described in 
     this paragraph include the following:
       ``(A) Section 2701 (adult health quality measures).
       ``(B) Section 2702 (payment adjustments for health care 
     acquired conditions).
       ``(C) Section 3001 (Hospital Value-Based Purchase Program).
       ``(D) Section 3002 (improvements to the Physician Quality 
     Reporting Initiative).
       ``(E) Section 3003 (improvements to the Physician Feedback 
     Program).
       ``(F) Section 3007 (value based payment modifier under 
     physician fee schedule).
       ``(G) Section 3008 (payment adjustment for conditions 
     acquired in hospitals).
       ``(H) Section 3013 (quality measure development).
       ``(I) Section 3014 (quality measurement).
       ``(J) Section 3021 (Establishment of Center for Medicare 
     and Medicaid Innovation).
       ``(K) Section 3025 (hospital readmission reduction 
     program).
       ``(L) Section 3501 (health care delivery system research, 
     quality improvement).

[[Page 32763]]

       ``(M) Section 4003 (Task Force on Clinical and Preventive 
     Services).
       ``(N) Section 4301 (research to optimize deliver of public 
     health services).
       ``(b) Report.--Not later than 2 years after the date of 
     enactment of this Act, the Comptroller General of the United 
     States shall submit to the appropriate committees of 
     Congress, a report containing the findings made by the 
     Comptroller General under the study under subsection (a).''.

     SEC. 10202. INCENTIVES FOR STATES TO OFFER HOME AND 
                   COMMUNITY-BASED SERVICES AS A LONG-TERM CARE 
                   ALTERNATIVE TO NURSING HOMES.

       (a) State Balancing Incentive Payments Program.--
     Notwithstanding section 1905(b) of the Social Security Act 
     (42 U.S.C. 1396d(b)), in the case of a balancing incentive 
     payment State, as defined in subsection (b), that meets the 
     conditions described in subsection (c), during the balancing 
     incentive period, the Federal medical assistance percentage 
     determined for the State under section 1905(b) of such Act 
     and, if applicable, increased under subsection (z) or (aa) 
     shall be increased by the applicable percentage points 
     determined under subsection (d) with respect to eligible 
     medical assistance expenditures described in subsection (e).
       (b) Balancing Incentive Payment State.--A balancing 
     incentive payment State is a State--
       (1) in which less than 50 percent of the total expenditures 
     for medical assistance under the State Medicaid program for a 
     fiscal year for long-term services and supports (as defined 
     by the Secretary under subsection (f))(1)) are for non-
     institutionally-based long-term services and supports 
     described in subsection (f)(1)(B);
       (2) that submits an application and meets the conditions 
     described in subsection (c); and
       (3) that is selected by the Secretary to participate in the 
     State balancing incentive payment program established under 
     this section.
       (c) Conditions.--The conditions described in this 
     subsection are the following:
       (1) Application.--The State submits an application to the 
     Secretary that includes, in addition to such other 
     information as the Secretary shall require--
       (A) a proposed budget that details the State's plan to 
     expand and diversify medical assistance for non-
     institutionally-based long-term services and supports 
     described in subsection (f)(1)(B) under the State Medicaid 
     program during the balancing incentive period and achieve the 
     target spending percentage applicable to the State under 
     paragraph (2), including through structural changes to how 
     the State furnishes such assistance, such as through the 
     establishment of a ``no wrong door - single entry point 
     system'', optional presumptive eligibility, case management 
     services, and the use of core standardized assessment 
     instruments, and that includes a description of the new or 
     expanded offerings of such services that the State will 
     provide and the projected costs of such services; and
       (B) in the case of a State that proposes to expand the 
     provision of home and community-based services under its 
     State Medicaid program through a State plan amendment under 
     section 1915(i) of the Social Security Act, at the option of 
     the State, an election to increase the income eligibility for 
     such services from 150 percent of the poverty line to such 
     higher percentage as the State may establish for such 
     purpose, not to exceed 300 percent of the supplemental 
     security income benefit rate established by section 
     1611(b)(1) of the Social Security Act (42 U.S.C. 1382(b)(1)).
       (2) Target spending percentages.--
       (A) In the case of a balancing incentive payment State in 
     which less than 25 percent of the total expenditures for 
     long-term services and supports under the State Medicaid 
     program for fiscal year 2009 are for home and community-based 
     services, the target spending percentage for the State to 
     achieve by not later than October 1, 2015, is that 25 percent 
     of the total expenditures for long-term services and supports 
     under the State Medicaid program are for home and community-
     based services.
       (B) In the case of any other balancing incentive payment 
     State, the target spending percentage for the State to 
     achieve by not later than October 1, 2015, is that 50 percent 
     of the total expenditures for long-term services and supports 
     under the State Medicaid program are for home and community-
     based services.
       (3) Maintenance of eligibility requirements.--The State 
     does not apply eligibility standards, methodologies, or 
     procedures for determining eligibility for medical assistance 
     for non-institutionally-based long-term services and supports 
     described in subsection (f)(1)(B) under the State Medicaid 
     program that are more restrictive than the eligibility 
     standards, methodologies, or procedures in effect for such 
     purposes on December 31, 2010.
       (4) Use of additional funds.--The State agrees to use the 
     additional Federal funds paid to the State as a result of 
     this section only for purposes of providing new or expanded 
     offerings of non-institutionally-based long-term services and 
     supports described in subsection (f)(1)(B) under the State 
     Medicaid program.
       (5) Structural changes.--The State agrees to make, not 
     later than the end of the 6-month period that begins on the 
     date the State submits an application under this section, the 
     following changes:
       (A) ``No wrong door - single entry point system''.--
     Development of a statewide system to enable consumers to 
     access all long-term services and supports through an agency, 
     organization, coordinated network, or portal, in accordance 
     with such standards as the State shall establish and that 
     shall provide information regarding the availability of such 
     services, how to apply for such services, referral services 
     for services and supports otherwise available in the 
     community, and determinations of financial and functional 
     eligibility for such services and supports, or assistance 
     with assessment processes for financial and functional 
     eligibility.
       (B) Conflict-free case management services.--Conflict-free 
     case management services to develop a service plan, arrange 
     for services and supports, support the beneficiary (and, if 
     appropriate, the beneficiary's caregivers) in directing the 
     provision of services and supports for the beneficiary, and 
     conduct ongoing monitoring to assure that services and 
     supports are delivered to meet the beneficiary's needs and 
     achieve intended outcomes.
       (C) Core standardized assessment instruments.--Development 
     of core standardized assessment instruments for determining 
     eligibility for non-institutionally-based long-term services 
     and supports described in subsection (f)(1)(B), which shall 
     be used in a uniform manner throughout the State, to 
     determine a beneficiary's needs for training, support 
     services, medical care, transportation, and other services, 
     and develop an individual service plan to address such needs.
       (6) Data collection.--The State agrees to collect from 
     providers of services and through such other means as the 
     State determines appropriate the following data:
       (A) Services data.--Services data from providers of non-
     institutionally-based long-term services and supports 
     described in subsection (f)(1)(B) on a per-beneficiary basis 
     and in accordance with such standardized coding procedures as 
     the State shall establish in consultation with the Secretary.
       (B) Quality data.--Quality data on a selected set of core 
     quality measures agreed upon by the Secretary and the State 
     that are linked to population-specific outcomes measures and 
     accessible to providers.
       (C) Outcomes measures.--Outcomes measures data on a 
     selected set of core population-specific outcomes measures 
     agreed upon by the Secretary and the State that are 
     accessible to providers and include--
       (i) measures of beneficiary and family caregiver experience 
     with providers;
       (ii) measures of beneficiary and family caregiver 
     satisfaction with services; and
       (iii) measures for achieving desired outcomes appropriate 
     to a specific beneficiary, including employment, 
     participation in community life, health stability, and 
     prevention of loss in function.
       (d) Applicable Percentage Points Increase in FMAP.--The 
     applicable percentage points increase is--
       (1) in the case of a balancing incentive payment State 
     subject to the target spending percentage described in 
     subsection (c)(2)(A), 5 percentage points; and
       (2) in the case of any other balancing incentive payment 
     State, 2 percentage points.
       (e) Eligible Medical Assistance Expenditures.--
       (1) In general.--Subject to paragraph (2), medical 
     assistance described in this subsection is medical assistance 
     for non-institutionally-based long-term services and supports 
     described in subsection (f)(1)(B) that is provided by a 
     balancing incentive payment State under its State Medicaid 
     program during the balancing incentive payment period.
       (2) Limitation on payments.--In no case may the aggregate 
     amount of payments made by the Secretary to balancing 
     incentive payment States under this section during the 
     balancing incentive period exceed $3,000,000,000.
       (f) Definitions.--In this section:
       (1) Long-term services and supports defined.--The term 
     ``long-term services and supports'' has the meaning given 
     that term by Secretary and may include any of the following 
     (as defined for purposes of State Medicaid programs):
       (A) Institutionally-based long-term services and 
     supports.--Services provided in an institution, including the 
     following:
       (i) Nursing facility services.
       (ii) Services in an intermediate care facility for the 
     mentally retarded described in subsection (a)(15) of section 
     1905 of such Act.
       (B) Non-institutionally-based long-term services and 
     supports.--Services not provided in an institution, including 
     the following:
       (i) Home and community-based services provided under 
     subsection (c), (d), or (i) of section 1915 of such Act or 
     under a waiver under section 1115 of such Act.
       (ii) Home health care services.
       (iii) Personal care services.
       (iv) Services described in subsection (a)(26) of section 
     1905 of such Act (relating to PACE program services).
       (v) Self-directed personal assistance services described in 
     section 1915(j) of such Act.

[[Page 32764]]

       (2) Balancing incentive period.--The term ``balancing 
     incentive period'' means the period that begins on October 1, 
     2011, and ends on September 30, 2015.
       (3) Poverty line.--The term ``poverty line'' has the 
     meaning given that term in section 2110(c)(5) of the Social 
     Security Act (42 U.S.C. 1397jj(c)(5)).
       (4) State medicaid program.--The term ``State Medicaid 
     program'' means the State program for medical assistance 
     provided under a State plan under title XIX of the Social 
     Security Act and under any waiver approved with respect to 
     such State plan.

     SEC. 10203. EXTENSION OF FUNDING FOR CHIP THROUGH FISCAL YEAR 
                   2015 AND OTHER CHIP-RELATED PROVISIONS.

       (a) Section 1311(c)(1) of this Act is amended by striking 
     ``and'' at the end of subparagraph (G), by striking the 
     period at the end of subparagraph (H) and inserting ``; 
     and'', and by adding at the end the following:
       ``(I) report to the Secretary at least annually and in such 
     manner as the Secretary shall require, pediatric quality 
     reporting measures consistent with the pediatric quality 
     reporting measures established under section 1139A of the 
     Social Security Act.''.
       (b) Effective as if included in the enactment of the 
     Children's Health Insurance Program Reauthorization Act of 
     2009 (Public Law 111-3):
       (1) Section 1906(e)(2) of the Social Security Act (42 
     U.S.C. 1396e(e)(2)) is amended by striking ``means'' and all 
     that follows through the period and inserting ``has the 
     meaning given that term in section 2105(c)(3)(A).''.
       (2)(A) Section 1906A(a) of the Social Security Act (42 
     U.S.C. 1396e-1(a)), is amended by inserting before the period 
     the following: ``and the offering of such a subsidy is cost-
     effective, as defined for purposes of section 
     2105(c)(3)(A)''.
       (B) This Act shall be applied without regard to 
     subparagraph (A) of section 2003(a)(1) of this Act and that 
     subparagraph and the amendment made by that subparagraph are 
     hereby deemed null, void, and of no effect.
       (3) Section 2105(c)(10) of the Social Security Act (42 
     U.S.C. 1397ee(c)(10)) is amended--
       (A) in subparagraph (A), in the first sentence, by 
     inserting before the period the following: ``if the offering 
     of such a subsidy is cost-effective, as defined for purposes 
     of paragraph (3)(A)'';
       (B) by striking subparagraph (M); and
       (C) by redesignating subparagraph (N) as subparagraph (M).
       (4) Section 2105(c)(3)(A) of the Social Security Act (42 
     U.S.C. 1397ee(c)(3)(A)) is amended--
       (A) in the matter preceding clause (i), by striking ``to'' 
     and inserting ``to--''; and
       (B) in clause (ii), by striking the period and inserting a 
     semicolon.
       (c) Section 2105 of the Social Security Act (42 U.S.C. 
     1397ee), as amended by section 2101, is amended--
       (1) in subsection (b), in the second sentence, by striking 
     ``2013'' and inserting ``2015''; and
       (2) in subsection (d)(3)--
       (A) in subparagraph (A)--
       (i) in the first sentence, by inserting ``as a condition of 
     receiving payments under section 1903(a),'' after ``2019,'';
       (ii) in clause (i), by striking ``or'' at the end;
       (iii) by redesignating clause (ii) as clause (iii); and
       (iv) by inserting after clause (i), the following:
       ``(ii) after September 30, 2015, enrolling children 
     eligible to be targeted low-income children under the State 
     child health plan in a qualified health plan that has been 
     certified by the Secretary under subparagraph (C); or'';
       (B) in subparagraph (B), by striking ``provided coverage'' 
     and inserting ``screened for eligibility for medical 
     assistance under the State plan under title XIX or a waiver 
     of that plan and, if found eligible, enrolled in such plan or 
     a waiver. In the case of such children who, as a result of 
     such screening, are determined to not be eligible for medical 
     assistance under the State plan or a waiver under title XIX, 
     the State shall establish procedures to ensure that the 
     children are enrolled in a qualified health plan that has 
     been certified by the Secretary under subparagraph (C) and is 
     offered''; and
       (C) by adding at the end the following:
       ``(C) Certification of comparability of pediatric coverage 
     offered by qualified health plans.--With respect to each 
     State, the Secretary, not later than April 1, 2015, shall 
     review the benefits offered for children and the cost-sharing 
     imposed with respect to such benefits by qualified health 
     plans offered through an Exchange established by the State 
     under section 1311 of the Patient Protection and Affordable 
     Care Act and shall certify those plans that offer benefits 
     for children and impose cost-sharing with respect to such 
     benefits that the Secretary determines are at least 
     comparable to the benefits offered and cost-sharing 
     protections provided under the State child health plan.''.
       (d)(1) Section 2104(a) of such Act (42 U.S.C. 1397dd(a)) is 
     amended--
       (A) in paragraph (15), by striking ``and'' at the end; and
       (B) by striking paragraph (16) and inserting the following:
       ``(16) for fiscal year 2013, $17,406,000,000;
       ``(17) for fiscal year 2014, $19,147,000,000; and
       ``(18) for fiscal year 2015, for purposes of making 2 semi-
     annual allotments--
       ``(A) $2,850,000,000 for the period beginning on October 1, 
     2014, and ending on March 31, 2015, and
       ``(B) $2,850,000,000 for the period beginning on April 1, 
     2015, and ending on September 30, 2015.''.
       (2)(A) Section 2104(m) of such Act (42 U.S.C. 1397dd(m)), 
     as amended by section 2102(a)(1), is amended--
       (i) in the subsection heading, by striking ``2013'' and 
     inserting ``2015'';
       (ii) in paragraph (2)--
       (I) in the paragraph heading, by striking ``2012'' and 
     inserting ``2014''; and
       (II) by adding at the end the following:
       ``(B) Fiscal years 2013 and 2014.--Subject to paragraphs 
     (4) and (6), from the amount made available under paragraphs 
     (16) and (17) of subsection (a) for fiscal years 2013 and 
     2014, respectively, the Secretary shall compute a State 
     allotment for each State (including the District of Columbia 
     and each commonwealth and territory) for each such fiscal 
     year as follows:
       ``(i) Rebasing in fiscal year 2013.--For fiscal year 2013, 
     the allotment of the State is equal to the Federal payments 
     to the State that are attributable to (and countable towards) 
     the total amount of allotments available under this section 
     to the State in fiscal year 2012 (including payments made to 
     the State under subsection (n) for fiscal year 2012 as well 
     as amounts redistributed to the State in fiscal year 2012), 
     multiplied by the allotment increase factor under paragraph 
     (5) for fiscal year 2013.
       ``(ii) Growth factor update for fiscal year 2014.--For 
     fiscal year 2014, the allotment of the State is equal to the 
     sum of--

       ``(I) the amount of the State allotment under clause (i) 
     for fiscal year 2013; and
       ``(II) the amount of any payments made to the State under 
     subsection (n) for fiscal year 2013,

     multiplied by the allotment increase factor under paragraph 
     (5) for fiscal year 2014.'';
       (iii) in paragraph (3)--
       (I) in the paragraph heading, by striking ``2013'' and 
     inserting ``2015'';
       (II) in subparagraphs (A) and (B), by striking ``paragraph 
     (16)'' each place it appears and inserting ``paragraph 
     (18)'';
       (III) in subparagraph (C)--

       (aa) by striking ``2012'' each place it appears and 
     inserting ``2014''; and
       (bb) by striking ``2013'' and inserting ``2015''; and

       (IV) in subparagraph (D)--

       (aa) in clause (i)(I), by striking ``subsection 
     (a)(16)(A)'' and inserting ``subsection (a)(18)(A)''; and
       (bb) in clause (ii)(II), by striking ``subsection 
     (a)(16)(B)'' and inserting ``subsection (a)(18)(B)'';

       (iv) in paragraph (4), by striking ``2013'' and inserting 
     ``2015'';
       (v) in paragraph (6)--
       (I) in subparagraph (A), by striking ``2013'' and inserting 
     ``2015''; and
       (II) in the flush language after and below subparagraph 
     (B)(ii), by striking ``or fiscal year 2012'' and inserting 
     ``, fiscal year 2012, or fiscal year 2014''; and
       (vi) in paragraph (8)--
       (I) in the paragraph heading, by striking ``2013'' and 
     inserting ``2015''; and
       (II) by striking ``2013'' and inserting ``2015''.
       (B) Section 2104(n) of such Act (42 U.S.C. 1397dd(n)) is 
     amended--
       (i) in paragraph (2)--
       (I) in subparagraph (A)(ii)--
       (aa) by striking ``2012'' and inserting ``2014''; and
       (bb) by striking ``2013'' and inserting ``2015'';
       (II) in subparagraph (B)--
       (aa) by striking ``2012'' and inserting ``2014''; and
       (bb) by striking ``2013'' and inserting ``2015''; and
       (ii) in paragraph (3)(A), by striking ``or a semi-annual 
     allotment period for fiscal year 2013'' and inserting 
     ``fiscal year 2013, fiscal year 2014, or a semi-annual 
     allotment period for fiscal year 2015''.
       (C) Section 2105(g)(4) of such Act (42 U.S.C. 1397ee(g)(4)) 
     is amended--
       (i) in the paragraph heading, by striking ``2013'' and 
     inserting ``2015''; and
       (ii) in subparagraph (A), by striking ``2013'' and 
     inserting ``2015''.
       (D) Section 2110(b) of such Act (42 U.S.C. 1397jj(b)) is 
     amended--
       (i) in paragraph (2)(B), by inserting ``except as provided 
     in paragraph (6),'' before ``a child''; and
       (ii) by adding at the end the following new paragraph:
       ``(6) Exceptions to exclusion of children of employees of a 
     public agency in the state.--
       ``(A) In general.--A child shall not be considered to be 
     described in paragraph (2)(B) if--
       ``(i) the public agency that employs a member of the 
     child's family to which such paragraph applies satisfies 
     subparagraph (B); or
       ``(ii) subparagraph (C) applies to such child.
       ``(B) Maintenance of effort with respect to per person 
     agency contribution for family coverage.--For purposes of 
     subparagraph (A)(i), a public agency satisfies this

[[Page 32765]]

     subparagraph if the amount of annual agency expenditures made 
     on behalf of each employee enrolled in health coverage paid 
     for by the agency that includes dependent coverage for the 
     most recent State fiscal year is not less than the amount of 
     such expenditures made by the agency for the 1997 State 
     fiscal year, increased by the percentage increase in the 
     medical care expenditure category of the Consumer Price Index 
     for All-Urban Consumers (all items: U.S. City Average) for 
     such preceding fiscal year.
       ``(C) Hardship exception.--For purposes of subparagraph 
     (A)(ii), this subparagraph applies to a child if the State 
     determines, on a case-by-case basis, that the annual 
     aggregate amount of premiums and cost-sharing imposed for 
     coverage of the family of the child would exceed 5 percent of 
     such family's income for the year involved.''.
       (E) Section 2113 of such Act (42 U.S.C. 1397mm) is 
     amended--
       (i) in subsection (a)(1), by striking ``2013'' and 
     inserting ``2015''; and
       (ii) in subsection (g), by striking ``$100,000,000 for the 
     period of fiscal years 2009 through 2013'' and inserting 
     ``$140,000,000 for the period of fiscal years 2009 through 
     2015''.
       (F) Section 108 of Public Law 111-3 is amended by striking 
     ``$11,706,000,000'' and all that follows through the second 
     sentence and inserting ``$15,361,000,000 to accompany the 
     allotment made for the period beginning on October 1, 2014, 
     and ending on March 31, 2015, under section 2104(a)(18)(A) of 
     the Social Security Act (42 U.S.C. 1397dd(a)(18)(A)), to 
     remain available until expended. Such amount shall be used to 
     provide allotments to States under paragraph (3) of section 
     2104(m) of the Social Security Act (42 U.S.C. 1397dd(m)) for 
     the first 6 months of fiscal year 2015 in the same manner as 
     allotments are provided under subsection (a)(18)(A) of such 
     section 2104 and subject to the same terms and conditions as 
     apply to the allotments provided from such subsection 
     (a)(18)(A).''.

      PART II--SUPPORT FOR PREGNANT AND PARENTING TEENS AND WOMEN

     SEC. 10211. DEFINITIONS.

       In this part:
       (1) Accompaniment.--The term ``accompaniment'' means 
     assisting, representing, and accompanying a woman in seeking 
     judicial relief for child support, child custody, restraining 
     orders, and restitution for harm to persons and property, and 
     in filing criminal charges, and may include the payment of 
     court costs and reasonable attorney and witness fees 
     associated therewith.
       (2) Eligible institution of higher education.--The term 
     ``eligible institution of higher education'' means an 
     institution of higher education (as such term is defined in 
     section 101 of the Higher Education Act of 1965 (20 U.S.C. 
     1001)) that has established and operates, or agrees to 
     establish and operate upon the receipt of a grant under this 
     part, a pregnant and parenting student services office.
       (3) Community service center.--The term ``community service 
     center'' means a non-profit organization that provides social 
     services to residents of a specific geographical area via 
     direct service or by contract with a local governmental 
     agency.
       (4) High school.--The term ``high school'' means any public 
     or private school that operates grades 10 through 12, 
     inclusive, grades 9 through 12, inclusive or grades 7 through 
     12, inclusive.
       (5) Intervention services.--The term ``intervention 
     services'' means, with respect to domestic violence, sexual 
     violence, sexual assault, or stalking, 24-hour telephone 
     hotline services for police protection and referral to 
     shelters.
       (6) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (7) State.--The term ``State'' includes the District of 
     Columbia, any commonwealth, possession, or other territory of 
     the United States, and any Indian tribe or reservation.
       (8) Supportive social services.--The term ``supportive 
     social services'' means transitional and permanent housing, 
     vocational counseling, and individual and group counseling 
     aimed at preventing domestic violence, sexual violence, 
     sexual assault, or stalking.
       (9) Violence.--The term ``violence'' means actual violence 
     and the risk or threat of violence.

     SEC. 10212. ESTABLISHMENT OF PREGNANCY ASSISTANCE FUND.

       (a) In General.--The Secretary, in collaboration and 
     coordination with the Secretary of Education (as 
     appropriate), shall establish a Pregnancy Assistance Fund to 
     be administered by the Secretary, for the purpose of awarding 
     competitive grants to States to assist pregnant and parenting 
     teens and women.
       (b) Use of Fund.--A State may apply for a grant under 
     subsection (a) to carry out any activities provided for in 
     section 10213.
       (c) Applications.--To be eligible to receive a grant under 
     subsection (a), a State shall submit to the Secretary an 
     application at such time, in such manner, and containing such 
     information as the Secretary may require, including a 
     description of the purposes for which the grant is being 
     requested and the designation of a State agency for receipt 
     and administration of funding received under this part.

     SEC. 10213. PERMISSIBLE USES OF FUND.

       (a) In General.--A State shall use amounts received under a 
     grant under section 10212 for the purposes described in this 
     section to assist pregnant and parenting teens and women.
       (b) Institutions of Higher Education.--
       (1) In general.--A State may use amounts received under a 
     grant under section 10212 to make funding available to 
     eligible institutions of higher education to enable the 
     eligible institutions to establish, maintain, or operate 
     pregnant and parenting student services. Such funding shall 
     be used to supplement, not supplant, existing funding for 
     such services.
       (2) Application.--An eligible institution of higher 
     education that desires to receive funding under this 
     subsection shall submit an application to the designated 
     State agency at such time, in such manner, and containing 
     such information as the State agency may require.
       (3) Matching requirement.--An eligible institution of 
     higher education that receives funding under this subsection 
     shall contribute to the conduct of the pregnant and parenting 
     student services office supported by the funding an amount 
     from non-Federal funds equal to 25 percent of the amount of 
     the funding provided. The non-Federal share may be in cash or 
     in-kind, fairly evaluated, including services, facilities, 
     supplies, or equipment.
       (4) Use of funds for assisting pregnant and parenting 
     college students.--An eligible institution of higher 
     education that receives funding under this subsection shall 
     use such funds to establish, maintain or operate pregnant and 
     parenting student services and may use such funding for the 
     following programs and activities:
       (A) Conduct a needs assessment on campus and within the 
     local community--
       (i) to assess pregnancy and parenting resources, located on 
     the campus or within the local community, that are available 
     to meet the needs described in subparagraph (B); and
       (ii) to set goals for--

       (I) improving such resources for pregnant, parenting, and 
     prospective parenting students; and
       (II) improving access to such resources.

       (B) Annually assess the performance of the eligible 
     institution in meeting the following needs of students 
     enrolled in the eligible institution who are pregnant or are 
     parents:
       (i) The inclusion of maternity coverage and the 
     availability of riders for additional family members in 
     student health care.
       (ii) Family housing.
       (iii) Child care.
       (iv) Flexible or alternative academic scheduling, such as 
     telecommuting programs, to enable pregnant or parenting 
     students to continue their education or stay in school.
       (v) Education to improve parenting skills for mothers and 
     fathers and to strengthen marriages.
       (vi) Maternity and baby clothing, baby food (including 
     formula), baby furniture, and similar items to assist parents 
     and prospective parents in meeting the material needs of 
     their children.
       (vii) Post-partum counseling.
       (C) Identify public and private service providers, located 
     on the campus of the eligible institution or within the local 
     community, that are qualified to meet the needs described in 
     subparagraph (B), and establishes programs with qualified 
     providers to meet such needs.
       (D) Assist pregnant and parenting students, fathers or 
     spouses in locating and obtaining services that meet the 
     needs described in subparagraph (B).
       (E) If appropriate, provide referrals for prenatal care and 
     delivery, infant or foster care, or adoption, to a student 
     who requests such information. An office shall make such 
     referrals only to service providers that serve the following 
     types of individuals:
       (i) Parents.
       (ii) Prospective parents awaiting adoption.
       (iii) Women who are pregnant and plan on parenting or 
     placing the child for adoption.
       (iv) Parenting or prospective parenting couples.
       (5) Reporting.--
       (A) Annual report by institutions.--
       (i) In general.--For each fiscal year that an eligible 
     institution of higher education receives funds under this 
     subsection, the eligible institution shall prepare and submit 
     to the State, by the date determined by the State, a report 
     that--

       (I) itemizes the pregnant and parenting student services 
     office's expenditures for the fiscal year;
       (II) contains a review and evaluation of the performance of 
     the office in fulfilling the requirements of this section, 
     using the specific performance criteria or standards 
     established under subparagraph (B)(i); and
       (III) describes the achievement of the office in meeting 
     the needs listed in paragraph (4)(B) of the students served 
     by the eligible institution, and the frequency of use of the 
     office by such students.

       (ii) Performance criteria.--Not later than 180 days before 
     the date the annual report described in clause (i) is 
     submitted, the State--

       (I) shall identify the specific performance criteria or 
     standards that shall be used to prepare the report; and

[[Page 32766]]

       (II) may establish the form or format of the report.

       (B) Report by state.--The State shall annually prepare and 
     submit a report on the findings under this subsection, 
     including the number of eligible institutions of higher 
     education that were awarded funds and the number of students 
     served by each pregnant and parenting student services office 
     receiving funds under this section, to the Secretary.
       (c) Support for Pregnant and Parenting Teens.--A State may 
     use amounts received under a grant under section 10212 to 
     make funding available to eligible high schools and community 
     service centers to establish, maintain or operate pregnant 
     and parenting services in the same general manner and in 
     accordance with all conditions and requirements described in 
     subsection (b), except that paragraph (3) of such subsection 
     shall not apply for purposes of this subsection.
       (d) Improving Services for Pregnant Women Who Are Victims 
     of Domestic Violence, Sexual Violence, Sexual Assault, and 
     Stalking.--
       (1) In general.--A State may use amounts received under a 
     grant under section 10212 to make funding available tp its 
     State Attorney General to assist Statewide offices in 
     providing--
       (A) intervention services, accompaniment, and supportive 
     social services for eligible pregnant women who are victims 
     of domestic violence, sexual violence, sexual assault, or 
     stalking.
       (B) technical assistance and training (as described in 
     subsection (c)) relating to violence against eligible 
     pregnant women to be made available to the following:
       (i) Federal, State, tribal, territorial, and local 
     governments, law enforcement agencies, and courts.
       (ii) Professionals working in legal, social service, and 
     health care settings.
       (iii) Nonprofit organizations.
       (iv) Faith-based organizations.
       (2) Eligibility.--To be eligible for a grant under 
     paragraph (1), a State Attorney General shall submit an 
     application to the designated State agency at such time, in 
     such manner, and containing such information, as specified by 
     the State.
       (3) Technical assistance and training described.--For 
     purposes of paragraph (1)(B), technical assistance and 
     training is--
       (A) the identification of eligible pregnant women 
     experiencing domestic violence, sexual violence, sexual 
     assault, or stalking;
       (B) the assessment of the immediate and short-term safety 
     of such a pregnant woman, the evaluation of the impact of the 
     violence or stalking on the pregnant woman's health, and the 
     assistance of the pregnant woman in developing a plan aimed 
     at preventing further domestic violence, sexual violence, 
     sexual assault, or stalking, as appropriate;
       (C) the maintenance of complete medical or forensic records 
     that include the documentation of any examination, treatment 
     given, and referrals made, recording the location and nature 
     of the pregnant woman's injuries, and the establishment of 
     mechanisms to ensure the privacy and confidentiality of those 
     medical records; and
       (D) the identification and referral of the pregnant woman 
     to appropriate public and private nonprofit entities that 
     provide intervention services, accompaniment, and supportive 
     social services.
       (4) Eligible pregnant woman.--In this subsection, the term 
     ``eligible pregnant woman'' means any woman who is pregnant 
     on the date on which such woman becomes a victim of domestic 
     violence, sexual violence, sexual assault, or stalking or who 
     was pregnant during the one-year period before such date.
       (e) Public Awareness and Education.--A State may use 
     amounts received under a grant under section 10212 to make 
     funding available to increase public awareness and education 
     concerning any services available to pregnant and parenting 
     teens and women under this part, or any other resources 
     available to pregnant and parenting women in keeping with the 
     intent and purposes of this part. The State shall be 
     responsible for setting guidelines or limits as to how much 
     of funding may be utilized for public awareness and education 
     in any funding award.

     SEC. 10214. APPROPRIATIONS.

       There is authorized to be appropriated, and there are 
     appropriated, $25,000,000 for each of fiscal years 2010 
     through 2019, to carry out this part.

                PART III--INDIAN HEALTH CARE IMPROVEMENT

     SEC. 10221. INDIAN HEALTH CARE IMPROVEMENT.

       (a) In General.--Except as provided in subsection (b), S. 
     1790 entitled ``A bill to amend the Indian Health Care 
     Improvement Act to revise and extend that Act, and for other 
     purposes.'', as reported by the Committee on Indian Affairs 
     of the Senate in December 2009, is enacted into law.
       (b) Amendments.--
       (1) Section 119 of the Indian Health Care Improvement Act 
     (as amended by section 111 of the bill referred to in 
     subsection (a)) is amended--
       (A) in subsection (d)--
       (i) in paragraph (2), by striking ``In establishing'' and 
     inserting ``Subject to paragraphs (3) and (4), in 
     establishing''; and
       (ii) by adding at the end the following:
       ``(3) Election of indian tribe or tribal organization.--
       ``(A) In general.--Subparagraph (B) of paragraph (2) shall 
     not apply in the case of an election made by an Indian tribe 
     or tribal organization located in a State (other than Alaska) 
     in which the use of dental health aide therapist services or 
     midlevel dental health provider services is authorized under 
     State law to supply such services in accordance with State 
     law.
       ``(B) Action by secretary.--On an election by an Indian 
     tribe or tribal organization under subparagraph (A), the 
     Secretary, acting through the Service, shall facilitate 
     implementation of the services elected.
       ``(4) Vacancies.--The Secretary shall not fill any vacancy 
     for a certified dentist in a program operated by the Service 
     with a dental health aide therapist.''; and
       (B) by adding at the end the following:
       ``(e) Effect of Section.--Nothing in this section shall 
     restrict the ability of the Service, an Indian tribe, or a 
     tribal organization to participate in any program or to 
     provide any service authorized by any other Federal law.''.
       (2) The Indian Health Care Improvement Act (as amended by 
     section 134(b) of the bill referred to in subsection (a)) is 
     amended by striking section 125 (relating to treatment of 
     scholarships for certain purposes).
       (3) Section 806 of the Indian Health Care Improvement Act 
     (25 U.S.C. 1676) is amended--
       (A) by striking ``Any limitation'' and inserting the 
     following:
       ``(a) HHS Appropriations.--Any limitation''; and
       (B) by adding at the end the following:
       ``(b) Limitations Pursuant to Other Federal Law.--Any 
     limitation pursuant to other Federal laws on the use of 
     Federal funds appropriated to the Service shall apply with 
     respect to the performance or coverage of abortions.''.
       (4) The bill referred to in subsection (a) is amended by 
     striking section 201.

              Subtitle C--Provisions Relating to Title III

     SEC. 10301. PLANS FOR A VALUE-BASED PURCHASING PROGRAM FOR 
                   AMBULATORY SURGICAL CENTERS.

       (a) In General.--Section 3006 is amended by adding at the 
     end the following new subsection:
       ``(f) Ambulatory Surgical Centers.--
       ``(1) In general.--The Secretary shall develop a plan to 
     implement a value-based purchasing program for payments under 
     the Medicare program under title XVIII of the Social Security 
     Act for ambulatory surgical centers (as described in section 
     1833(i) of the Social Security Act (42 U.S.C. 1395l(i))).
       ``(2) Details.--In developing the plan under paragraph (1), 
     the Secretary shall consider the following issues:
       ``(A) The ongoing development, selection, and modification 
     process for measures (including under section 1890 of the 
     Social Security Act (42 U.S.C. 1395aaa) and section 1890A of 
     such Act, as added by section 3014), to the extent feasible 
     and practicable, of all dimensions of quality and efficiency 
     in ambulatory surgical centers.
       ``(B) The reporting, collection, and validation of quality 
     data.
       ``(C) The structure of value-based payment adjustments, 
     including the determination of thresholds or improvements in 
     quality that would substantiate a payment adjustment, the 
     size of such payments, and the sources of funding for the 
     value-based bonus payments.
       ``(D) Methods for the public disclosure of information on 
     the performance of ambulatory surgical centers.
       ``(E) Any other issues determined appropriate by the 
     Secretary.
       ``(3) Consultation.--In developing the plan under paragraph 
     (1), the Secretary shall--
       ``(A) consult with relevant affected parties; and
       ``(B) consider experience with such demonstrations that the 
     Secretary determines are relevant to the value-based 
     purchasing program described in paragraph (1).
       ``(4) Report to congress.--Not later than January 1, 2011, 
     the Secretary shall submit to Congress a report containing 
     the plan developed under paragraph (1).''.
       (b) Technical.--Section 3006(a)(2)(A) is amended by 
     striking clauses (i) and (ii).

     SEC. 10302. REVISION TO NATIONAL STRATEGY FOR QUALITY 
                   IMPROVEMENT IN HEALTH CARE.

       Section 399HH(a)(2)(B)(iii) of the Public Health Service 
     Act, as added by section 3011, is amended by inserting 
     ``(taking into consideration the limitations set forth in 
     subsections (c) and (d) of section 1182 of the Social 
     Security Act)'' after ``information''.

     SEC. 10303. DEVELOPMENT OF OUTCOME MEASURES.

       (a) Development.--Section 931 of the Public Health Service 
     Act, as added by section 3013(a), is amended by adding at the 
     end the following new subsection:
       ``(f) Development of Outcome Measures.--
       ``(1) In general.--The Secretary shall develop, and 
     periodically update (not less than every 3 years), provider-
     level outcome measures for hospitals and physicians, as well 
     as other providers as determined appropriate by the 
     Secretary.
       ``(2) Categories of measures.--The measures developed under 
     this subsection shall

[[Page 32767]]

     include, to the extent determined appropriate by the 
     Secretary--
       ``(A) outcome measurement for acute and chronic diseases, 
     including, to the extent feasible, the 5 most prevalent and 
     resource-intensive acute and chronic medical conditions; and
       ``(B) outcome measurement for primary and preventative 
     care, including, to the extent feasible, measurements that 
     cover provision of such care for distinct patient populations 
     (such as healthy children, chronically ill adults, or infirm 
     elderly individuals).
       ``(3) Goals.--In developing such measures, the Secretary 
     shall seek to--
       ``(A) address issues regarding risk adjustment, 
     accountability, and sample size;
       ``(B) include the full scope of services that comprise a 
     cycle of care; and
       ``(C) include multiple dimensions.
       ``(4) Timeframe.--
       ``(A) Acute and chronic diseases.--Not later than 24 months 
     after the date of enactment of this Act, the Secretary shall 
     develop not less than 10 measures described in paragraph 
     (2)(A).
       ``(B) Primary and preventive care.--Not later than 36 
     months after the date of enactment of this Act, the Secretary 
     shall develop not less than 10 measures described in 
     paragraph (2)(B).''.
       (b) Hospital-Acquired Conditions.--Section 1890A of the 
     Social Security Act, as amended by section 3013(b), is 
     amended by adding at the end the following new subsection:
       ``(f) Hospital Acquired Conditions.--The Secretary shall, 
     to the extent practicable, publicly report on measures for 
     hospital-acquired conditions that are currently utilized by 
     the Centers for Medicare & Medicaid Services for the 
     adjustment of the amount of payment to hospitals based on 
     rates of hospital-acquired infections.''.
       (c) Clinical Practice Guidelines.--Section 304(b) of the 
     Medicare Improvements for Patients and Providers Act of 2008 
     (Public Law 110-275) is amended by adding at the end the 
     following new paragraph:
       ``(4) Identification.--
       ``(A) In general.--Following receipt of the report 
     submitted under paragraph (2), and not less than every 3 
     years thereafter, the Secretary shall contract with the 
     Institute to employ the results of the study performed under 
     paragraph (1) and the best methods identified by the 
     Institute for the purpose of identifying existing and new 
     clinical practice guidelines that were developed using such 
     best methods, including guidelines listed in the National 
     Guideline Clearinghouse.
       ``(B) Consultation.--In carrying out the identification 
     process under subparagraph (A), the Secretary shall allow for 
     consultation with professional societies, voluntary health 
     care organizations, and expert panels.''.

     SEC. 10304. SELECTION OF EFFICIENCY MEASURES.

       Sections 1890(b)(7) and 1890A of the Social Security Act, 
     as added by section 3014, are amended by striking ``quality'' 
     each place it appears and inserting ``quality and 
     efficiency''.

     SEC. 10305. DATA COLLECTION; PUBLIC REPORTING.

       Section 399II(a) of the Public Health Service Act, as added 
     by section 3015, is amended to read as follows:
       ``(a) In General.--
       ``(1) Establishment of strategic framework.--The Secretary 
     shall establish and implement an overall strategic framework 
     to carry out the public reporting of performance information, 
     as described in section 399JJ. Such strategic framework may 
     include methods and related timelines for implementing 
     nationally consistent data collection, data aggregation, and 
     analysis methods.
       ``(2) Collection and aggregation of data.--The Secretary 
     shall collect and aggregate consistent data on quality and 
     resource use measures from information systems used to 
     support health care delivery, and may award grants or 
     contracts for this purpose. The Secretary shall align such 
     collection and aggregation efforts with the requirements and 
     assistance regarding the expansion of health information 
     technology systems, the interoperability of such technology 
     systems, and related standards that are in effect on the date 
     of enactment of the Patient Protection and Affordable Care 
     Act.
       ``(3) Scope.--The Secretary shall ensure that the data 
     collection, data aggregation, and analysis systems described 
     in paragraph (1) involve an increasingly broad range of 
     patient populations, providers, and geographic areas over 
     time.''.

     SEC. 10306. IMPROVEMENTS UNDER THE CENTER FOR MEDICARE AND 
                   MEDICAID INNOVATION.

       Section 1115A of the Social Security Act, as added by 
     section 3021, is amended--
       (1) in subsection (a), by inserting at the end the 
     following new paragraph:
       ``(5) Testing within certain geographic areas.--For 
     purposes of testing payment and service delivery models under 
     this section, the Secretary may elect to limit testing of a 
     model to certain geographic areas.'';
       (2) in subsection (b)(2)--
       (A) in subparagraph (A)--
       (i) in the second sentence, by striking ``the preceding 
     sentence may include'' and inserting ``this subparagraph may 
     include, but are not limited to,''; and
       (ii) by inserting after the first sentence the following 
     new sentence: ``The Secretary shall focus on models expected 
     to reduce program costs under the applicable title while 
     preserving or enhancing the quality of care received by 
     individuals receiving benefits under such title.'';
       (B) in subparagraph (B), by adding at the end the following 
     new clauses:
       ``(xix) Utilizing, in particular in entities located in 
     medically underserved areas and facilities of the Indian 
     Health Service (whether operated by such Service or by an 
     Indian tribe or tribal organization (as those terms are 
     defined in section 4 of the Indian Health Care Improvement 
     Act)), telehealth services--

       ``(I) in treating behavioral health issues (such as post-
     traumatic stress disorder) and stroke; and
       ``(II) to improve the capacity of non-medical providers and 
     non-specialized medical providers to provide health services 
     for patients with chronic complex conditions.

       ``(xx) Utilizing a diverse network of providers of services 
     and suppliers to improve care coordination for applicable 
     individuals described in subsection (a)(4)(A)(i) with 2 or 
     more chronic conditions and a history of prior-year 
     hospitalization through interventions developed under the 
     Medicare Coordinated Care Demonstration Project under section 
     4016 of the Balanced Budget Act of 1997 (42 U.S.C. 1395b-1 
     note).''; and
       (C) in subparagraph (C), by adding at the end the following 
     new clause:
       ``(viii) Whether the model demonstrates effective linkage 
     with other public sector or private sector payers.'';
       (3) in subsection (b)(4), by adding at the end the 
     following new subparagraph:
       ``(C) Measure selection.--To the extent feasible, the 
     Secretary shall select measures under this paragraph that 
     reflect national priorities for quality improvement and 
     patient-centered care consistent with the measures described 
     in 1890(b)(7)(B).''; and
       (4) in subsection (c)--
       (A) in paragraph (1)(B), by striking ``care and reduce 
     spending; and'' and inserting ``patient care without 
     increasing spending;'';
       (B) in paragraph (2), by striking ``reduce program spending 
     under applicable titles.'' and inserting ``reduce (or would 
     not result in any increase in) net program spending under 
     applicable titles; and''; and
       (C) by adding at the end the following:
       ``(3) the Secretary determines that such expansion would 
     not deny or limit the coverage or provision of benefits under 
     the applicable title for applicable individuals.

     In determining which models or demonstration projects to 
     expand under the preceding sentence, the Secretary shall 
     focus on models and demonstration projects that improve the 
     quality of patient care and reduce spending.''.

     SEC. 10307. IMPROVEMENTS TO THE MEDICARE SHARED SAVINGS 
                   PROGRAM.

       Section 1899 of the Social Security Act, as added by 
     section 3022, is amended by adding at the end the following 
     new subsections:
       ``(i) Option To Use Other Payment Models.--
       ``(1) In general.--If the Secretary determines appropriate, 
     the Secretary may use any of the payment models described in 
     paragraph (2) or (3) for making payments under the program 
     rather than the payment model described in subsection (d).
       ``(2) Partial capitation model.--
       ``(A) In general.--Subject to subparagraph (B), a model 
     described in this paragraph is a partial capitation model in 
     which an ACO is at financial risk for some, but not all, of 
     the items and services covered under parts A and B, such as 
     at risk for some or all physicians' services or all items and 
     services under part B. The Secretary may limit a partial 
     capitation model to ACOs that are highly integrated systems 
     of care and to ACOs capable of bearing risk, as determined to 
     be appropriate by the Secretary.
       ``(B) No additional program expenditures.--Payments to an 
     ACO for items and services under this title for beneficiaries 
     for a year under the partial capitation model shall be 
     established in a manner that does not result in spending more 
     for such ACO for such beneficiaries than would otherwise be 
     expended for such ACO for such beneficiaries for such year if 
     the model were not implemented, as estimated by the 
     Secretary.
       ``(3) Other payment models.--
       ``(A) In general.--Subject to subparagraph (B), a model 
     described in this paragraph is any payment model that the 
     Secretary determines will improve the quality and efficiency 
     of items and services furnished under this title.
       ``(B) No additional program expenditures.--Subparagraph (B) 
     of paragraph (2) shall apply to a payment model under 
     subparagraph (A) in a similar manner as such subparagraph (B) 
     applies to the payment model under paragraph (2).
       ``(j) Involvement in Private Payer and Other Third Party 
     Arrangements.--The Secretary may give preference to ACOs who 
     are participating in similar arrangements with other payers.
       ``(k) Treatment of Physician Group Practice 
     Demonstration.--During the period beginning on the date of 
     the enactment of this

[[Page 32768]]

     section and ending on the date the program is established, 
     the Secretary may enter into an agreement with an ACO under 
     the demonstration under section 1866A, subject to rebasing 
     and other modifications deemed appropriate by the 
     Secretary.''.

     SEC. 10308. REVISIONS TO NATIONAL PILOT PROGRAM ON PAYMENT 
                   BUNDLING.

       (a) In General.--Section 1866D of the Social Security Act, 
     as added by section 3023, is amended--
       (1) in paragraph (a)(2)(B), in the matter preceding clause 
     (i), by striking ``8 conditions'' and inserting ``10 
     conditions'';
       (2) by striking subsection (c)(1)(B) and inserting the 
     following:
       ``(B) Expansion.--The Secretary may, at any point after 
     January 1, 2016, expand the duration and scope of the pilot 
     program, to the extent determined appropriate by the 
     Secretary, if--
       ``(i) the Secretary determines that such expansion is 
     expected to--

       ``(I) reduce spending under title XVIII of the Social 
     Security Act without reducing the quality of care; or
       ``(II) improve the quality of care and reduce spending;

       ``(ii) the Chief Actuary of the Centers for Medicare & 
     Medicaid Services certifies that such expansion would reduce 
     program spending under such title XVIII; and
       ``(iii) the Secretary determines that such expansion would 
     not deny or limit the coverage or provision of benefits under 
     this title for individuals.''; and
       (3) by striking subsection (g) and inserting the following 
     new subsection:
       ``(g) Application of Pilot Program to Continuing Care 
     Hospitals.--
       ``(1) In general.--In conducting the pilot program, the 
     Secretary shall apply the provisions of the program so as to 
     separately pilot test the continuing care hospital model.
       ``(2) Special rules.--In pilot testing the continuing care 
     hospital model under paragraph (1), the following rules shall 
     apply:
       ``(A) Such model shall be tested without the limitation to 
     the conditions selected under subsection (a)(2)(B).
       ``(B) Notwithstanding subsection (a)(2)(D), an episode of 
     care shall be defined as the full period that a patient stays 
     in the continuing care hospital plus the first 30 days 
     following discharge from such hospital.
       ``(3) Continuing care hospital defined.--In this 
     subsection, the term `continuing care hospital' means an 
     entity that has demonstrated the ability to meet patient care 
     and patient safety standards and that provides under common 
     management the medical and rehabilitation services provided 
     in inpatient rehabilitation hospitals and units (as defined 
     in section 1886(d)(1)(B)(ii)), long term care hospitals (as 
     defined in 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).''.
       (b) Technical Amendments.--
       (1) Section 3023 is amended by striking ``1886C'' and 
     inserting ``1866C''.
       (2) Title XVIII of the Social Security Act is amended by 
     redesignating section 1866D, as added by section 3024, as 
     section 1866E.

     SEC. 10309. REVISIONS TO HOSPITAL READMISSIONS REDUCTION 
                   PROGRAM.

       Section 1886(q)(1) of the Social Security Act, as added by 
     section 3025, in the matter preceding subparagraph (A), is 
     amended by striking ``the Secretary shall reduce the 
     payments'' and all that follows through ``the product of'' 
     and inserting ``the Secretary shall make payments (in 
     addition to the payments described in paragraph (2)(A)(ii)) 
     for such a discharge to such hospital under subsection (d) 
     (or section 1814(b)(3), as the case may be) in an amount 
     equal to the product of''.

     SEC. 10310. REPEAL OF PHYSICIAN PAYMENT UPDATE.

       The provisions of, and the amendment made by, section 3101 
     are repealed

     SEC. 10311. REVISIONS TO EXTENSION OF AMBULANCE ADD-ONS.

       (a) Ground Ambulance.--Section 1834(l)(13)(A) of the Social 
     Security Act (42 U.S.C. 1395m(l)(13)(A)), as amended by 
     section 3105(a), is further amended--
       (1) in the matter preceding clause (i)--
       (A) by striking ``2007, for'' and inserting ``2007, and 
     for''; and
       (B) by striking ``2010, and for such services furnished on 
     or after April 1, 2010, and before January 1, 2011'' and 
     inserting ``2011''; and
       (2) in each of clauses (i) and (ii)--
       (A) by striking ``, and on or after April 1, 2010, and 
     before January 1, 2011'' each place it appears; and
       (B) by striking ``January 1, 2010'' and inserting ``January 
     1, 2011'' each place it appears.
       (b) Air Ambulance.--Section 146(b)(1) of the Medicare 
     Improvements for Patients and Providers Act of 2008 (Public 
     Law 110-275), as amended by section 3105(b), is further 
     amended by striking ``December 31, 2009, and during the 
     period beginning on April 1, 2010, and ending on January 1, 
     2011'' and inserting ``December 31, 2010''.
       (c) Super Rural Ambulance.--Section 1834(l)(12)(A) of the 
     Social Security Act (42 U.S.C. 1395m(l)(12)(A)), as amended 
     by section 3105(c), is further amended by striking ``2010, 
     and on or after April 1, 2010, and before January 1, 2011'' 
     and inserting ``2011''.

     SEC. 10312. CERTAIN PAYMENT RULES FOR LONG-TERM CARE HOSPITAL 
                   SERVICES AND MORATORIUM ON THE ESTABLISHMENT OF 
                   CERTAIN HOSPITALS AND FACILITIES.

       (a) Certain Payment Rules.--Section 114(c) of the Medicare, 
     Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395ww 
     note), as amended by section 4302(a) of the American Recovery 
     and Reinvestment Act (Public Law 111-5) and section 3106(a) 
     of this Act, is further amended by striking ``4-year period'' 
     each place it appears and inserting ``5-year period''.
       (b) Moratorium.--Section 114(d) of such Act (42 U.S.C. 
     1395ww note), as amended by section 3106(b) of this Act, in 
     the matter preceding subparagraph (A), is amended by striking 
     ``4-year period'' and inserting ``5-year period''.

     SEC. 10313. REVISIONS TO THE EXTENSION FOR THE RURAL 
                   COMMUNITY HOSPITAL DEMONSTRATION PROGRAM.

       (a) In General.--Subsection (g) of section 410A of the 
     Medicare Prescription Drug, Improvement, and Modernization 
     Act of 2003 (Public Law 108-173; 117 Stat. 2272), as added by 
     section 3123(a) of this Act, is amended to read as follows:
       ``(g) Five-Year Extension of Demonstration Program.--
       ``(1) In general.--Subject to the succeeding provisions of 
     this subsection, the Secretary shall conduct the 
     demonstration program under this section for an additional 5-
     year period (in this section referred to as the `5-year 
     extension period') that begins on the date immediately 
     following the last day of the initial 5-year period under 
     subsection (a)(5).
       ``(2) Expansion of demonstration states.--Notwithstanding 
     subsection (a)(2), during the 5-year extension period, the 
     Secretary shall expand the number of States with low 
     population densities determined by the Secretary under such 
     subsection to 20. In determining which States to include in 
     such expansion, the Secretary shall use the same criteria and 
     data that the Secretary used to determine the States under 
     such subsection for purposes of the initial 5-year period.
       ``(3) Increase in maximum number of hospitals participating 
     in the demonstration program.--Notwithstanding subsection 
     (a)(4), during the 5-year extension period, not more than 30 
     rural community hospitals may participate in the 
     demonstration program under this section.
       ``(4) Hospitals in demonstration program on date of 
     enactment.--In the case of a rural community hospital that is 
     participating in the demonstration program under this section 
     as of the last day of the initial 5-year period, the 
     Secretary--
       ``(A) shall provide for the continued participation of such 
     rural community hospital in the demonstration program during 
     the 5-year extension period unless the rural community 
     hospital makes an election, in such form and manner as the 
     Secretary may specify, to discontinue such participation; and
       ``(B) in calculating the amount of payment under subsection 
     (b) to the rural community hospital for covered inpatient 
     hospital services furnished by the hospital during such 5-
     year extension period, shall substitute, under paragraph 
     (1)(A) of such subsection--
       ``(i) the reasonable costs of providing such services for 
     discharges occurring in the first cost reporting period 
     beginning on or after the first day of the 5-year extension 
     period, for
       ``(ii) the reasonable costs of providing such services for 
     discharges occurring in the first cost reporting period 
     beginning on or after the implementation of the demonstration 
     program.''.
       (b) Conforming Amendments.--Subsection (a)(5) of section 
     410A of the Medicare Prescription Drug, Improvement, and 
     Modernization Act of 2003 (Public Law 108-173; 117 Stat. 
     2272), as amended by section 3123(b) of this Act, is amended 
     by striking ``1-year extension'' and inserting ``5-year 
     extension''.

     SEC. 10314. ADJUSTMENT TO LOW-VOLUME HOSPITAL PROVISION.

       Section 1886(d)(12) of the Social Security Act (42 U.S.C. 
     1395ww(d)(12), as amended by section 3125, is amended--
       (1) in subparagraph (C)(i), by striking ``1,500 
     discharges'' and inserting ``1,600 discharges''; and
       (2) in subparagraph (D), by striking ``1,500 discharges'' 
     and inserting ``1,600 discharges''.

     SEC. 10315. REVISIONS TO HOME HEALTH CARE PROVISIONS.

       (a) Rebasing.--Section 1895(b)(3)(A)(iii) of the Social 
     Security Act, as added by section 3131, is amended--
       (1) in the clause heading, by striking ``2013'' and 
     inserting ``2014'';
       (2) in subclause (I), by striking ``2013'' and inserting 
     ``2014''; and
       (3) in subclause (II), by striking ``2016'' and inserting 
     ``2017''.
       (b) Revision of Home Health Study and Report.--Section 
     3131(d) is amended to read as follows:
       ``(d) Study and Report on the Development of Home Health 
     Payment Revisions in Order to Ensure Access to Care and 
     Payment for Severity of Illness.--
       ``(1) In general.--The Secretary of Health and Human 
     Services (in this section referred to as the `Secretary') 
     shall conduct a study

[[Page 32769]]

     on home health agency costs involved with providing ongoing 
     access to care to low-income Medicare beneficiaries or 
     beneficiaries in medically underserved areas, and in treating 
     beneficiaries with varying levels of severity of illness. In 
     conducting the study, the Secretary may analyze items such as 
     the following:
       ``(A) Methods to potentially revise the home health 
     prospective payment system under section 1895 of the Social 
     Security Act (42 U.S.C. 1395fff) to account for costs related 
     to patient severity of illness or to improving beneficiary 
     access to care, such as--
       ``(i) payment adjustments for services that may involve 
     additional or fewer resources;
       ``(ii) changes to reflect resources involved with providing 
     home health services to low-income Medicare beneficiaries or 
     Medicare beneficiaries residing in medically underserved 
     areas;
       ``(iii) ways outlier payments might be revised to reflect 
     costs of treating Medicare beneficiaries with high levels of 
     severity of illness; and
       ``(iv) other issues determined appropriate by the 
     Secretary.
       ``(B) Operational issues involved with potential 
     implementation of potential revisions to the home health 
     payment system, including impacts for both home health 
     agencies and administrative and systems issues for the 
     Centers for Medicare & Medicaid Services, and any possible 
     payment vulnerabilities associated with implementing 
     potential revisions.
       ``(C) Whether additional research might be needed.
       ``(D) Other items determined appropriate by the Secretary.
       ``(2) Considerations.--In conducting the study under 
     paragraph (1), the Secretary may consider whether patient 
     severity of illness and access to care could be measured by 
     factors, such as--
       ``(A) population density and relative patient access to 
     care;
       ``(B) variations in service costs for providing care to 
     individuals who are dually eligible under the Medicare and 
     Medicaid programs;
       ``(C) the presence of severe or chronic diseases, which 
     might be measured by multiple, discontinuous home health 
     episodes;
       ``(D) poverty status, such as evidenced by the receipt of 
     Supplemental Security Income under title XVI of the Social 
     Security Act; and
       ``(E) other factors determined appropriate by the 
     Secretary.
       ``(3) Report.--Not later than March 1, 2014, the Secretary 
     shall submit to Congress a report on the study conducted 
     under paragraph (1), together with recommendations for such 
     legislation and administrative action as the Secretary 
     determines appropriate.
       ``(4) Consultations.--In conducting the study under 
     paragraph (1), the Secretary shall consult with appropriate 
     stakeholders, such as groups representing home health 
     agencies and groups representing Medicare beneficiaries.
       ``(5) Medicare demonstration project based on the results 
     of the study.--
       ``(A) In general.--Subject to subparagraph (D), taking into 
     account the results of the study conducted under paragraph 
     (1), the Secretary may, as determined appropriate, provide 
     for a demonstration project to test whether making payment 
     adjustments for home health services under the Medicare 
     program would substantially improve access to care for 
     patients with high severity levels of illness or for low-
     income or underserved Medicare beneficiaries.
       ``(B) Waiving budget neutrality.--The Secretary shall not 
     reduce the standard prospective payment amount (or amounts) 
     under section 1895 of the Social Security Act (42 U.S.C. 
     1395fff) applicable to home health services furnished during 
     a period to offset any increase in payments during such 
     period resulting from the application of the payment 
     adjustments under subparagraph (A).
       ``(C) No effect on subsequent periods.--A payment 
     adjustment resulting from the application of subparagraph (A) 
     for a period--
       ``(i) shall not apply to payments for home health services 
     under title XVIII after such period; and
       ``(ii) shall not be taken into account in calculating the 
     payment amounts applicable for such services after such 
     period.
       ``(D) Duration.--If the Secretary determines it appropriate 
     to conduct the demonstration project under this subsection, 
     the Secretary shall conduct the project for a four year 
     period beginning not later than January 1, 2015.
       ``(E) Funding.--The Secretary shall provide for the 
     transfer from the Federal Hospital Insurance Trust Fund under 
     section 1817 of the Social Security Act (42 U.S.C. 1395i) and 
     the Federal Supplementary Medical Insurance Trust Fund 
     established under section 1841 of such Act (42 U.S.C. 1395t), 
     in such proportion as the Secretary determines appropriate, 
     of $500,000,000 for the period of fiscal years 2015 through 
     2018. Such funds shall be made available for the study 
     described in paragraph (1) and the design, implementation and 
     evaluation of the demonstration described in this paragraph. 
     Amounts available under this subparagraph shall be available 
     until expended.
       ``(F) Evaluation and report.--If the Secretary determines 
     it appropriate to conduct the demonstration project under 
     this subsection, the Secretary shall--
       ``(i) provide for an evaluation of the project; and
       ``(ii) submit to Congress, by a date specified by the 
     Secretary, a report on the project.
       ``(G) Administration.--Chapter 35 of title 44, United 
     States Code, shall not apply with respect to this 
     subsection.''.

     SEC. 10316. MEDICARE DSH.

       Section 1886(r)(2)(B) of the Social Security Act, as added 
     by section 3133, is amended--
       (1) in clause (i)--
       (A) in the matter preceding subclause (I), by striking 
     ``(divided by 100)'';
       (B) in subclause (I), by striking ``2012'' and inserting 
     ``2013'';
       (C) in subclause (II), by striking the period at the end 
     and inserting a comma; and
       (D) by adding at the end the following flush matter:
     ``minus 1.5 percentage points.''.
       (2) in clause (ii)--
       (A) in the matter preceding subclause (I), by striking 
     ``(divided by 100)'';
       (B) in subclause (I), by striking ``2012'' and inserting 
     ``2013'';
       (C) in subclause (II), by striking the period at the end 
     and inserting a comma; and
       (D) by adding at the end the following flush matter:

     ``and, for each of 2018 and 2019, minus 1.5 percentage 
     points.''.

     SEC. 10317. REVISIONS TO EXTENSION OF SECTION 508 HOSPITAL 
                   PROVISIONS.

       Section 3137(a) is amended to read as follows:
       ``(a) Extension.--
       ``(1) In general.--Subsection (a) of section 106 of 
     division B of the Tax Relief and Health Care Act of 2006 (42 
     U.S.C. 1395 note), as amended by section 117 of the Medicare, 
     Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-
     173) and section 124 of the Medicare Improvements for 
     Patients and Providers Act of 2008 (Public Law 110-275), is 
     amended by striking `September 30, 2009' and inserting 
     `September 30, 2010'.
       ``(2) Special rule for fiscal year 2010.--
       ``(A) In general.--Subject to subparagraph (B), for 
     purposes of implementation of the amendment made by paragraph 
     (1), including (notwithstanding paragraph (3) of section 
     117(a) of the Medicare, Medicaid and SCHIP Extension Act of 
     2007 (Public Law 110-173), as amended by section 124(b) of 
     the Medicare Improvements for Patients and Providers Act of 
     2008 (Public Law 110-275)) for purposes of the implementation 
     of paragraph (2) of such section 117(a), during fiscal year 
     2010, the Secretary of Health and Human Services (in this 
     subsection referred to as the `Secretary') shall use the 
     hospital wage index that was promulgated by the Secretary in 
     the Federal Register on August 27, 2009 (74 Fed. Reg. 43754), 
     and any subsequent corrections.
       ``(B) Exception.--Beginning on April 1, 2010, in 
     determining the wage index applicable to hospitals that 
     qualify for wage index reclassification, the Secretary shall 
     include the average hourly wage data of hospitals whose 
     reclassification was extended pursuant to the amendment made 
     by paragraph (1) only if including such data results in a 
     higher applicable reclassified wage index.
       ``(3) Adjustment for certain hospitals in fiscal year 
     2010.--
       ``(A) In general.--In the case of a subsection (d) hospital 
     (as defined in subsection (d)(1)(B) of section 1886 of the 
     Social Security Act (42 U.S.C. 1395ww)) with respect to 
     which--
       ``(i) a reclassification of its wage index for purposes of 
     such section was extended pursuant to the amendment made by 
     paragraph (1); and
       ``(ii) the wage index applicable for such hospital for the 
     period beginning on October 1, 2009, and ending on March 31, 
     2010, was lower than for the period beginning on April 1, 
     2010, and ending on September 30, 2010, by reason of the 
     application of paragraph (2)(B);
     the Secretary shall pay such hospital an additional payment 
     that reflects the difference between the wage index for such 
     periods.
       ``(B) Timeframe for payments.--The Secretary shall make 
     payments required under subparagraph by not later than 
     December 31, 2010.''.

     SEC. 10318. REVISIONS TO TRANSITIONAL EXTRA BENEFITS UNDER 
                   MEDICARE ADVANTAGE.

       Section 1853(p)(3)(A) of the Social Security Act, as added 
     by section 3201(h), is amended by inserting ``in 2009'' 
     before the period at the end.

     SEC. 10319. REVISIONS TO MARKET BASKET ADJUSTMENTS.

       (a) Inpatient Acute Hospitals.--Section 1886(b)(3)(B)(xii) 
     of the Social Security Act, as added by section 3401(a), is 
     amended--
       (1) in subclause (I), by striking ``and'' at the end;
       (2) by redesignating subclause (II) as subclause (III);
       (3) by inserting after subclause (II) the following new 
     subclause:
       ``(II) for each of fiscal years 2012 and 2013, by 0.1 
     percentage point; and''; and
       (4) in subclause (III), as redesignated by paragraph (2), 
     by striking ``2012'' and inserting ``2014''.
       (b) Long-Term Care Hospitals.--Section 1886(m)(4) of the 
     Social Security Act, as added by section 3401(c), is 
     amended--

[[Page 32770]]

       (1) in subparagraph (A)--
       (A) in clause (i)--
       (i) by striking ``each of rate years 2010 and 2011'' and 
     inserting ``rate year 2010''; and
       (ii) by striking ``and'' at the end;
       (B) by redesignating clause (ii) as clause (iv);
       (C) by inserting after clause (i) the following new 
     clauses:
       ``(ii) for rate year 2011, 0.50 percentage point;
       ``(iii) for each of the rate years beginning in 2012 and 
     2013, 0.1 percentage point; and''; and
       (D) in clause (iv), as redesignated by subparagraph (B), by 
     striking ``2012'' and inserting ``2014''; and
       (2) in subparagraph (B), by striking ``(A)(ii)'' and 
     inserting ``(A)(iv)''.
       (c) Inpatient Rehabilitation Facilities.--Section 
     1886(j)(3)(D)(i) of the Social Security Act, as added by 
     section 3401(d), is amended--
       (1) in subclause (I), by striking ``and'' at the end;
       (2) by redesignating subclause (II) as subclause (III);
       (3) by inserting after subclause (II) the following new 
     subclause:

       ``(II) for each of fiscal years 2012 and 2013, 0.1 
     percentage point; and''; and

       (4) in subclause (III), as redesignated by paragraph (2), 
     by striking ``2012'' and inserting ``2014''.
       (d) Home Health Agencies.--Section 1895(b)(3)(B)(vi)(II) of 
     such Act, as added by section 3401(e), is amended by striking 
     ``and 2012'' and inserting ``, 2012, and 2013''.
       (e) Psychiatric Hospitals.--Section 1886(s)(3)(A) of the 
     Social Security Act, as added by section 3401(f), is 
     amended--
       (1) in clause (i), by striking ``and'' at the end;
       (2) by redesignating clause (ii) as clause (iii);
       (3) by inserting after clause (ii) the following new 
     clause:
       ``(ii) for each of the rate years beginning in 2012 and 
     2013, 0.1 percentage point; and''; and
       (4) in clause (iii), as redesignated by paragraph (2), by 
     striking ``2012'' and inserting ``2014''.
       (f) Hospice Care.--Section 1814(i)(1)(C) of the Social 
     Security Act (42 U.S.C. 1395f(i)(1)(C)), as amended by 
     section 3401(g), is amended--
       (1) in clause (iv)(II), by striking ``0.5'' and inserting 
     ``0.3''; and
       (2) in clause (v), in the matter preceding subclause (I), 
     by striking ``0.5'' and inserting ``0.3''.
       (g) Outpatient Hospitals.--Section 1833(t)(3)(G)(i) of the 
     Social Security Act, as added by section 3401(i), is 
     amended--
       (1) in subclause (I), by striking ``and'' at the end;
       (2) by redesignating subclause (II) as subclause (III);
       (3) by inserting after subclause (II) the following new 
     subclause:

       ``(II) for each of 2012 and 2013, 0.1 percentage point; 
     and''; and

       (4) in subclause (III), as redesignated by paragraph (2), 
     by striking ``2012'' and inserting ``2014''.

     SEC. 10320. EXPANSION OF THE SCOPE OF, AND ADDITIONAL 
                   IMPROVEMENTS TO, THE INDEPENDENT MEDICARE 
                   ADVISORY BOARD.

       (a) In General.--Section 1899A of the Social Security Act, 
     as added by section 3403, is amended--
       (1) in subsection (c)--
       (A) in paragraph (1)(B), by adding at the end the following 
     new sentence: ``In any year (beginning with 2014) that the 
     Board is not required to submit a proposal under this 
     section, the Board shall submit to Congress an advisory 
     report on matters related to the Medicare program.'';
       (B) in paragraph (2)(A)--
       (i) in clause (iv), by inserting ``or the full premium 
     subsidy under section 1860D-14(a)'' before the period at the 
     end of the last sentence; and
       (ii) by adding at the end the following new clause:
       ``(vii) If the Chief Actuary of the Centers for Medicare & 
     Medicaid Services has made a determination described in 
     subsection (e)(3)(B)(i)(II) in the determination year, the 
     proposal shall be designed to help reduce the growth rate 
     described in paragraph (8) while maintaining or enhancing 
     beneficiary access to quality care under this title.'';
       (C) in paragraph (2)(B)--
       (i) in clause (v), by striking ``and'' at the end;
       (ii) in clause (vi), by striking the period at the end and 
     inserting ``; and''; and
       (iii) by adding at the end the following new clause:
       ``(vii) take into account the data and findings contained 
     in the annual reports under subsection (n) in order to 
     develop proposals that can most effectively promote the 
     delivery of efficient, high quality care to Medicare 
     beneficiaries.'';
       (D) in paragraph (3)--
       (i) in the heading, by striking ``Transmission of board 
     proposal to president'' and inserting ``Submission of board 
     proposal to congress and the president'';
       (ii) in subparagraph (A)(i), by striking ``transmit a 
     proposal under this section to the President'' and insert 
     ``submit a proposal under this section to Congress and the 
     President''; and
       (iii) in subparagraph (A)(ii)--

       (I) in subclause (I), by inserting ``or'' at the end;
       (II) in subclause (II), by striking ``; or'' and inserting 
     a period; and
       (III) by striking subclause (III);

       (E) in paragraph (4)--
       (i) by striking ``the Board under paragraph (3)(A)(i) or''; 
     and
       (ii) by striking ``immediately'' and inserting ``within 2 
     days'';
       (F) in paragraph (5)--
       (i) by striking ``to but'' and inserting ``but''; and
       (ii) by inserting ``Congress and'' after ``submit a 
     proposal to''; and
       (G) in paragraph (6)(B)(i), by striking ``per unduplicated 
     enrollee'' and inserting ``(calculated as the sum of per 
     capita spending under each of parts A, B, and D)'';
       (2) in subsection (d)--
       (A) in paragraph (1)(A)--
       (i) by inserting ``the Board or'' after ``a proposal is 
     submitted by''; and
       (ii) by inserting ``subsection (c)(3)(A)(i) or'' after 
     ``the Senate under''; and
       (B) in paragraph (2)(A), by inserting ``the Board or'' 
     after ``a proposal is submitted by'';
       (3) in subsection (e)--
       (A) in paragraph (1), by inserting ``the Board or'' after 
     ``a proposal submitted by''; and
       (B) in paragraph (3)--
       (i) by striking ``Exception.--The Secretary shall not be 
     required to implement the recommendations contained in a 
     proposal submitted in a proposal year by'' and inserting 
     ``Exceptions.--
       ``(A) In general.--The Secretary shall not implement the 
     recommendations contained in a proposal submitted in a 
     proposal year by the Board or'';
       (ii) by redesignating subparagraphs (A) and (B) as clauses 
     (i) and (ii), respectively, and indenting appropriately; and
       (iii) by adding at the end the following new subparagraph:
       ``(B) Limited additional exception.--
       ``(i) In general.--Subject to clause (ii), the Secretary 
     shall not implement the recommendations contained in a 
     proposal submitted by the Board or the President to Congress 
     pursuant to this section in a proposal year (beginning with 
     proposal year 2019) if--

       ``(I) the Board was required to submit a proposal to 
     Congress under this section in the year preceding the 
     proposal year; and
       ``(II) the Chief Actuary of the Centers for Medicare & 
     Medicaid Services makes a determination in the determination 
     year that the growth rate described in subsection (c)(8) 
     exceeds the growth rate described in subsection (c)(6)(A)(i).

       ``(ii) Limited additional exception may not be applied in 
     two consecutive years.--This subparagraph shall not apply if 
     the recommendations contained in a proposal submitted by the 
     Board or the President to Congress pursuant to this section 
     in the year preceding the proposal year were not required to 
     be implemented by reason of this subparagraph.
       ``(iii) No affect on requirement to submit proposals or for 
     congressional consideration of proposals.--Clause (i) and 
     (ii) shall not affect--

       ``(I) the requirement of the Board or the President to 
     submit a proposal to Congress in a proposal year in 
     accordance with the provisions of this section; or
       ``(II) Congressional consideration of a legislative 
     proposal (described in subsection (c)(3)(B)(iv)) contained 
     such a proposal in accordance with subsection (d).'';

       (4) in subsection (f)(3)(B)--
       (A) by striking ``or advisory reports to Congress'' and 
     inserting ``, advisory reports, or advisory 
     recommendations''; and
       (B) by inserting ``or produce the public report under 
     subsection (n)'' after ``this section''; and
       (5) by adding at the end the following new subsections:
       ``(n) Annual Public Report.--
       ``(1) In general.--Not later than July 1, 2014, and 
     annually thereafter, the Board shall produce a public report 
     containing standardized information on system-wide health 
     care costs, patient access to care, utilization, and quality-
     of-care that allows for comparison by region, types of 
     services, types of providers, and both private payers and the 
     program under this title.
       ``(2) Requirements.--Each report produced pursuant to 
     paragraph (1) shall include information with respect to the 
     following areas:
       ``(A) The quality and costs of care for the population at 
     the most local level determined practical by the Board (with 
     quality and costs compared to national benchmarks and 
     reflecting rates of change, taking into account quality 
     measures described in section 1890(b)(7)(B)).
       ``(B) Beneficiary and consumer access to care, patient and 
     caregiver experience of care, and the cost-sharing or out-of-
     pocket burden on patients.
       ``(C) Epidemiological shifts and demographic changes.
       ``(D) The proliferation, effectiveness, and utilization of 
     health care technologies, including variation in provider 
     practice patterns and costs.

[[Page 32771]]

       ``(E) Any other areas that the Board determines affect 
     overall spending and quality of care in the private sector.
       ``(o) Advisory Recommendations for Non-Federal Health Care 
     Programs.--
       ``(1) In general.--Not later than January 15, 2015, and at 
     least once every two years thereafter, the Board shall submit 
     to Congress and the President recommendations to slow the 
     growth in national health expenditures (excluding 
     expenditures under this title and in other Federal health 
     care programs) while preserving or enhancing quality of care, 
     such as recommendations--
       ``(A) that the Secretary or other Federal agencies can 
     implement administratively;
       ``(B) that may require legislation to be enacted by 
     Congress in order to be implemented;
       ``(C) that may require legislation to be enacted by State 
     or local governments in order to be implemented;
       ``(D) that private sector entities can voluntarily 
     implement; and
       ``(E) with respect to other areas determined appropriate by 
     the Board.
       ``(2) Coordination.--In making recommendations under 
     paragraph (1), the Board shall coordinate such 
     recommendations with recommendations contained in proposals 
     and advisory reports produced by the Board under subsection 
     (c).
       ``(3) Available to public.--The Board shall make 
     recommendations submitted to Congress and the President under 
     this subsection available to the public.''.
       (b) Name Change.--Any reference in the provisions of, or 
     amendments made by, section 3403 to the ``Independent 
     Medicare Advisory Board'' shall be deemed to be a reference 
     to the ``Independent Payment Advisory Board''.
       (c) Rule of Construction.--Nothing in the amendments made 
     by this section shall preclude the Independent Medicare 
     Advisory Board, as established under section 1899A of the 
     Social Security Act (as added by section 3403), from solely 
     using data from public or private sources to carry out the 
     amendments made by subsection (a)(4).

     SEC. 10321. REVISION TO COMMUNITY HEALTH TEAMS.

       Section 3502(c)(2)(A) is amended by inserting ``or other 
     primary care providers'' after ``physicians''.

     SEC. 10322. QUALITY REPORTING FOR PSYCHIATRIC HOSPITALS.

       (a) In General.--Section 1886(s) of the Social Security 
     Act, as added by section 3401(f), is amended by adding at the 
     end the following new paragraph:
       ``(4) Quality reporting.--
       ``(A) Reduction in update for failure to report.--
       ``(i) In general.--Under the system described in paragraph 
     (1), for rate year 2014 and each subsequent rate year, in the 
     case of a psychiatric hospital or psychiatric unit that does 
     not submit data to the Secretary in accordance with 
     subparagraph (C) with respect to such a rate year, any annual 
     update to a standard Federal rate for discharges for the 
     hospital during the rate year, and after application of 
     paragraph (2), shall be reduced by 2 percentage points.
       ``(ii) Special rule.--The application of this subparagraph 
     may result in such annual update being less than 0.0 for a 
     rate year, and may result in payment rates under the system 
     described in paragraph (1) for a rate year being less than 
     such payment rates for the preceding rate year.
       ``(B) Noncumulative application.--Any reduction under 
     subparagraph (A) shall apply only with respect to the rate 
     year involved and the Secretary shall not take into account 
     such reduction in computing the payment amount under the 
     system described in paragraph (1) for a subsequent rate year.
       ``(C) Submission of quality data.--For rate year 2014 and 
     each subsequent rate year, each psychiatric hospital and 
     psychiatric unit shall submit to the Secretary data on 
     quality measures specified under subparagraph (D). Such data 
     shall be submitted in a form and manner, and at a time, 
     specified by the Secretary for purposes of this subparagraph.
       ``(D) Quality measures.--
       ``(i) In general.--Subject to clause (ii), any measure 
     specified by the Secretary under this subparagraph must have 
     been endorsed by the entity with a contract under section 
     1890(a).
       ``(ii) Exception.--In the case of a specified area or 
     medical topic determined appropriate by the Secretary for 
     which a feasible and practical measure has not been endorsed 
     by the entity with a contract under section 1890(a), the 
     Secretary may specify a measure that is not so endorsed as 
     long as due consideration is given to measures that have been 
     endorsed or adopted by a consensus organization identified by 
     the Secretary.
       ``(iii) Time frame.--Not later than October 1, 2012, the 
     Secretary shall publish the measures selected under this 
     subparagraph that will be applicable with respect to rate 
     year 2014.
       ``(E) Public availability of data submitted.--The Secretary 
     shall establish procedures for making data submitted under 
     subparagraph (C) available to the public. Such procedures 
     shall ensure that a psychiatric hospital and a psychiatric 
     unit has the opportunity to review the data that is to be 
     made public with respect to the hospital or unit prior to 
     such data being made public. The Secretary shall report 
     quality measures that relate to services furnished in 
     inpatient settings in psychiatric hospitals and psychiatric 
     units on the Internet website of the Centers for Medicare & 
     Medicaid Services.''.
       (b) Conforming Amendment.--Section 1890(b)(7)(B)(i)(I) of 
     the Social Security Act, as added by section 3014, is amended 
     by inserting ``1886(s)(4)(D),'' after ``1886(o)(2),''.

     SEC. 10323. MEDICARE COVERAGE FOR INDIVIDUALS EXPOSED TO 
                   ENVIRONMENTAL HEALTH HAZARDS.

       (a) In General.--Title XVIII of the Social Security Act (42 
     U.S.C. 1395 et seq.) is amended by inserting after section 
     1881 the following new section:

     ``SEC. 1881A. MEDICARE COVERAGE FOR INDIVIDUALS EXPOSED TO 
                   ENVIRONMENTAL HEALTH HAZARDS.

       ``(a) Deeming of Individuals as Eligible for Medicare 
     Benefits.--
       ``(1) In general.--For purposes of eligibility for benefits 
     under this title, an individual determined under subsection 
     (c) to be an environmental exposure affected individual 
     described in subsection (e)(2) shall be deemed to meet the 
     conditions specified in section 226(a).
       ``(2) Discretionary deeming.--For purposes of eligibility 
     for benefits under this title, the Secretary may deem an 
     individual determined under subsection (c) to be an 
     environmental exposure affected individual described in 
     subsection (e)(3) to meet the conditions specified in section 
     226(a).
       ``(3) Effective date of coverage.--An Individual who is 
     deemed eligible for benefits under this title under paragraph 
     (1) or (2) shall be--
       ``(A) entitled to benefits under the program under Part A 
     as of the date of such deeming; and
       ``(B) eligible to enroll in the program under Part B 
     beginning with the month in which such deeming occurs.
       ``(b) Pilot Program for Care of Certain Individuals 
     Residing in Emergency Declaration Areas.--
       ``(1) Program; purpose.--
       ``(A) Primary pilot program.--The Secretary shall establish 
     a pilot program in accordance with this subsection to provide 
     innovative approaches to furnishing comprehensive, 
     coordinated, and cost-effective care under this title to 
     individuals described in paragraph (2)(A).
       ``(B) Optional pilot programs.--The Secretary may establish 
     a separate pilot program, in accordance with this subsection, 
     with respect to each geographic area subject to an emergency 
     declaration (other than the declaration of June 17, 2009), in 
     order to furnish such comprehensive, coordinated and cost-
     effective care to individuals described in subparagraph 
     (2)(B) who reside in each such area.
       ``(2) Individual described.--For purposes of paragraph (1), 
     an individual described in this paragraph is an individual 
     who enrolls in part B, submits to the Secretary an 
     application to participate in the applicable pilot program 
     under this subsection, and--
       ``(A) is an environmental exposure affected individual 
     described in subsection (e)(2) who resides in or around the 
     geographic area subject to an emergency declaration made as 
     of June 17, 2009; or
       ``(B) is an environmental exposure affected individual 
     described in subsection (e)(3) who--
       ``(i) is deemed under subsection (a)(2); and
       ``(ii) meets such other criteria or conditions for 
     participation in a pilot program under paragraph (1)(B) as 
     the Secretary specifies.
       ``(3) Flexible benefits and services.--A pilot program 
     under this subsection may provide for the furnishing of 
     benefits, items, or services not otherwise covered or 
     authorized under this title, if the Secretary determines that 
     furnishing such benefits, items, or services will further the 
     purposes of such pilot program (as described in paragraph 
     (1)).
       ``(4) Innovative reimbursement methodologies.--For purposes 
     of the pilot program under this subsection, the Secretary--
       ``(A) shall develop and implement appropriate methodologies 
     to reimburse providers for furnishing benefits, items, or 
     services for which payment is not otherwise covered or 
     authorized under this title, if such benefits, items, or 
     services are furnished pursuant to paragraph (3); and
       ``(B) may develop and implement innovative approaches to 
     reimbursing providers for any benefits, items, or services 
     furnished under this subsection.
       ``(5) Limitation.--Consistent with section 1862(b), no 
     payment shall be made under the pilot program under this 
     subsection with respect to benefits, items, or services 
     furnished to an environmental exposure affected individual 
     (as defined in subsection (e)) to the extent that such 
     individual is eligible to receive such benefits, items, or 
     services through any other public or private benefits plan or 
     legal agreement.
       ``(6) Waiver authority.--The Secretary may waive such 
     provisions of this title and title XI as are necessary to 
     carry out pilot programs under this subsection.
       ``(7) Funding.--For purposes of carrying out pilot programs 
     under this subsection, the

[[Page 32772]]

     Secretary shall provide for the transfer, from the Federal 
     Hospital Insurance Trust Fund under section 1817 and the 
     Federal Supplementary Medical Insurance Trust Fund under 
     section 1841, in such proportion as the Secretary determines 
     appropriate, of such sums as the Secretary determines 
     necessary, to the Centers for Medicare & Medicaid Services 
     Program Management Account.
       ``(8) Waiver of budget neutrality.--The Secretary shall not 
     require that pilot programs under this subsection be budget 
     neutral with respect to expenditures under this title.
       ``(c) Determinations.--
       ``(1) By the commissioner of social security.--For purposes 
     of this section, the Commissioner of Social Security, in 
     consultation with the Secretary, and using the cost 
     allocation method prescribed in section 201(g), shall 
     determine whether individuals are environmental exposure 
     affected individuals.
       ``(2) By the secretary.--The Secretary shall determine 
     eligibility for pilot programs under subsection (b).
       ``(d) Emergency Declaration Defined.--For purposes of this 
     section, the term `emergency declaration' means a declaration 
     of a public health emergency under section 104(a) of the 
     Comprehensive Environmental Response, Compensation, and 
     Liability Act of 1980.
       ``(e) Environmental Exposure Affected Individual Defined.--
       ``(1) In general.--For purposes of this section, the term 
     `environmental exposure affected individual' means--
       ``(A) an individual described in paragraph (2); and
       ``(B) an individual described in paragraph (3).
       ``(2) Individual described.--
       ``(A) In general.--An individual described in this 
     paragraph is any individual who--
       ``(i) is diagnosed with 1 or more conditions described in 
     subparagraph (B);
       ``(ii) as demonstrated in such manner as the Secretary 
     determines appropriate, has been present for an aggregate 
     total of 6 months in the geographic area subject to an 
     emergency declaration specified in subsection (b)(2)(A), 
     during a period ending--

       ``(I) not less than 10 years prior to such diagnosis; and
       ``(II) prior to the implementation of all the remedial and 
     removal actions specified in the Record of Decision for 
     Operating Unit 4 and the Record of Decision for Operating 
     Unit 7;

       ``(iii) files an application for benefits under this title 
     (or has an application filed on behalf of the individual), 
     including pursuant to this section; and
       ``(iv) is determined under this section to meet the 
     criteria in this subparagraph.
       ``(B) Conditions described.--For purposes of subparagraph 
     (A), the following conditions are described in this 
     subparagraph:
       ``(i) Asbestosis, pleural thickening, or pleural plaques as 
     established by--

       ``(I) interpretation by a `B Reader' qualified physician of 
     a plain chest x-ray or interpretation of a computed 
     tomographic radiograph of the chest by a qualified physician, 
     as determined by the Secretary; or
       ``(II) such other diagnostic standards as the Secretary 
     specifies,

     except that this clause shall not apply to pleural thickening 
     or pleural plaques unless there are symptoms or conditions 
     requiring medical treatment as a result of these diagnoses.
       ``(ii) Mesothelioma, or malignancies of the lung, colon, 
     rectum, larynx, stomach, esophagus, pharynx, or ovary, as 
     established by--

       ``(I) pathologic examination of biopsy tissue;
       ``(II) cytology from bronchioalveolar lavage; or
       ``(III) such other diagnostic standards as the Secretary 
     specifies.

       ``(iii) Any other diagnosis which the Secretary, in 
     consultation with the Commissioner of Social Security, 
     determines is an asbestos-related medical condition, as 
     established by such diagnostic standards as the Secretary 
     specifies.
       ``(3) Other individual described.--An individual described 
     in this paragraph is any individual who--
       ``(A) is not an individual described in paragraph (2);
       ``(B) is diagnosed with a medical condition caused by the 
     exposure of the individual to a public health hazard to which 
     an emergency declaration applies, based on such medical 
     conditions, diagnostic standards, and other criteria as the 
     Secretary specifies;
       ``(C) as demonstrated in such manner as the Secretary 
     determines appropriate, has been present for an aggregate 
     total of 6 months in the geographic area subject to the 
     emergency declaration involved, during a period determined 
     appropriate by the Secretary;
       ``(D) files an application for benefits under this title 
     (or has an application filed on behalf of the individual), 
     including pursuant to this section; and
       ``(E) is determined under this section to meet the criteria 
     in this paragraph.''.
       (b) Program for Early Detection of Certain Medical 
     Conditions Related to Environmental Health Hazards.--Title XX 
     of the Social Security Act (42 U.S.C. 1397 et seq.), as 
     amended by section 5507, is amended by adding at the end the 
     following:

     ``SEC. 2009. PROGRAM FOR EARLY DETECTION OF CERTAIN MEDICAL 
                   CONDITIONS RELATED TO ENVIRONMENTAL HEALTH 
                   HAZARDS.

       ``(a) Program Establishment.--The Secretary shall establish 
     a program in accordance with this section to make competitive 
     grants to eligible entities specified in subsection (b) for 
     the purpose of--
       ``(1) screening at-risk individuals (as defined in 
     subsection (c)(1)) for environmental health conditions (as 
     defined in subsection (c)(3)); and
       ``(2) developing and disseminating public information and 
     education concerning--
       ``(A) the availability of screening under the program under 
     this section;
       ``(B) the detection, prevention, and treatment of 
     environmental health conditions; and
       ``(C) the availability of Medicare benefits for certain 
     individuals diagnosed with environmental health conditions 
     under section 1881A.
       ``(b) Eligible Entities.--
       ``(1) In general.--For purposes of this section, an 
     eligible entity is an entity described in paragraph (2) which 
     submits an application to the Secretary in such form and 
     manner, and containing such information and assurances, as 
     the Secretary determines appropriate.
       ``(2) Types of eligible entities.--The entities described 
     in this paragraph are the following:
       ``(A) A hospital or community health center.
       ``(B) A Federally qualified health center.
       ``(C) A facility of the Indian Health Service.
       ``(D) A National Cancer Institute-designated cancer center.
       ``(E) An agency of any State or local government.
       ``(F) A nonprofit organization.
       ``(G) Any other entity the Secretary determines 
     appropriate.
       ``(c) Definitions.--In this section:
       ``(1) At-risk individual.--The term `at-risk individual' 
     means an individual who--
       ``(A)(i) as demonstrated in such manner as the Secretary 
     determines appropriate, has been present for an aggregate 
     total of 6 months in the geographic area subject to an 
     emergency declaration specified under paragraph (2), during a 
     period ending--
       ``(I) not less than 10 years prior to the date of such 
     individual's application under subparagraph (B); and
       ``(II) prior to the implementation of all the remedial and 
     removal actions specified in the Record of Decision for 
     Operating Unit 4 and the Record of Decision for Operating 
     Unit 7; or
       ``(ii) meets such other criteria as the Secretary 
     determines appropriate considering the type of environmental 
     health condition at issue; and
       ``(B) has submitted an application (or has an application 
     submitted on the individual's behalf), to an eligible entity 
     receiving a grant under this section, for screening under the 
     program under this section.
       ``(2) Emergency declaration.--The term `emergency 
     declaration' means a declaration of a public health emergency 
     under section 104(a) of the Comprehensive Environmental 
     Response, Compensation, and Liability Act of 1980.
       ``(3) Environmental health condition.--The term 
     `environmental health condition' means--
       ``(A) asbestosis, pleural thickening, or pleural plaques, 
     as established by--
       ``(i) interpretation by a `B Reader' qualified physician of 
     a plain chest x-ray or interpretation of a computed 
     tomographic radiograph of the chest by a qualified physician, 
     as determined by the Secretary; or
       ``(ii) such other diagnostic standards as the Secretary 
     specifies;
       ``(B) mesothelioma, or malignancies of the lung, colon, 
     rectum, larynx, stomach, esophagus, pharynx, or ovary, as 
     established by---
       ``(i) pathologic examination of biopsy tissue;
       ``(ii) cytology from bronchioalveolar lavage; or
       ``(iii) such other diagnostic standards as the Secretary 
     specifies; and
       ``(C) any other medical condition which the Secretary 
     determines is caused by exposure to a hazardous substance or 
     pollutant or contaminant at a Superfund site to which an 
     emergency declaration applies, based on such criteria and as 
     established by such diagnostic standards as the Secretary 
     specifies.
       ``(4) Hazardous substance; pollutant; contaminant.--The 
     terms `hazardous substance', `pollutant', and `contaminant' 
     have the meanings given those terms in section 101 of the 
     Comprehensive Environmental Response, Compensation, and 
     Liability Act of 1980 (42 U.S.C. 9601).
       ``(5) Superfund site.--The term `Superfund site' means a 
     site included on the National Priorities List developed by 
     the President in accordance with section 105(a)(8)(B) of the 
     Comprehensive Environmental Response, Compensation, and 
     Liability Act of 1980 (42 U.S.C. 9605(a)(8)(B)).
       ``(d) Health Coverage Unaffected.--Nothing in this section 
     shall be construed to affect any coverage obligation of a 
     governmental or private health plan or program relating to an 
     at-risk individual.

[[Page 32773]]

       ``(e) Funding.--
       ``(1) In general.--Out of any funds in the Treasury not 
     otherwise appropriated, there are appropriated to the 
     Secretary, to carry out the program under this section--
       ``(A) $23,000,000 for the period of fiscal years 2010 
     through 2014; and
       ``(B) $20,000,000 for each 5-fiscal year period thereafter.
       ``(2) Availability.--Funds appropriated under paragraph (1) 
     shall remain available until expended.
       ``(f) Nonapplication.--
       ``(1) In general.--Except as provided in paragraph (2), the 
     preceding sections of this title shall not apply to grants 
     awarded under this section.
       ``(2) Limitations on use of grants.--Section 2005(a) shall 
     apply to a grant awarded under this section to the same 
     extent and in the same manner as such section applies to 
     payments to States under this title, except that paragraph 
     (4) of such section shall not be construed to prohibit 
     grantees from conducting screening for environmental health 
     conditions as authorized under this section.''.

     SEC. 10324. PROTECTIONS FOR FRONTIER STATES.

       (a) Floor on Area Wage Index for Hospitals in Frontier 
     States.--
       (1) In general.--Section 1886(d)(3)(E) of the Social 
     Security Act (42 U.S.C. 1395ww(d)(3)(E)) is amended--
       (A) in clause (i), by striking ``clause (ii)'' and 
     inserting ``clause (ii) or (iii)''; and
       (B) by adding at the end the following new clause:
       ``(iii) Floor on area wage index for hospitals in frontier 
     states.--

       ``(I) In general.--Subject to subclause (IV), for 
     discharges occurring on or after October 1, 2010, the area 
     wage index applicable under this subparagraph to any hospital 
     which is located in a frontier State (as defined in subclause 
     (II)) may not be less than 1.00.
       ``(II) Frontier state defined.--In this clause, the term 
     `frontier State' means a State in which at least 50 percent 
     of the counties in the State are frontier counties.
       ``(III) Frontier county defined.--In this clause, the term 
     `frontier county' means a county in which the population per 
     square mile is less than 6.
       ``(IV) Limitation.--This clause shall not apply to any 
     hospital located in a State that receives a non-labor related 
     share adjustment under paragraph (5)(H).''.

       (2) Waiving budget neutrality.--Section 1886(d)(3)(E) of 
     the Social Security Act (42 U.S.C. 1395ww(d)(3)(E)), as 
     amended by subsection (a), is amended in the third sentence 
     by inserting ``and the amendments made by section 10324(a)(1) 
     of the Patient Protection and Affordable Care Act'' after 
     ``2003''.
       (b) Floor on Area Wage Adjustment Factor for Hospital 
     Outpatient Department Services in Frontier States.--Section 
     1833(t) of the Social Security Act (42 U.S.C. 1395l(t)), as 
     amended by section 3138, is amended--
       (1) in paragraph (2)(D), by striking ``the Secretary'' and 
     inserting ``subject to paragraph (19), the Secretary''; and
       (2) by adding at the end the following new paragraph:
       ``(19) Floor on area wage adjustment factor for hospital 
     outpatient department services in frontier states.--
       ``(A) In general.--Subject to subparagraph (B), with 
     respect to covered OPD services furnished on or after January 
     1, 2011, the area wage adjustment factor applicable under the 
     payment system established under this subsection to any 
     hospital outpatient department which is located in a frontier 
     State (as defined in section 1886(d)(3)(E)(iii)(II)) may not 
     be less than 1.00. The preceding sentence shall not be 
     applied in a budget neutral manner.
       ``(B) Limitation.--This paragraph shall not apply to any 
     hospital outpatient department located in a State that 
     receives a non-labor related share adjustment under section 
     1886(d)(5)(H).''.
       (c) Floor for Practice Expense Index for Physicians' 
     Services Furnished in Frontier States.--Section 1848(e)(1) of 
     the Social Security Act (42 U.S.C. 1395w-4(e)(1)), as amended 
     by section 3102, is amended--
       (1) in subparagraph (A), by striking ``and (H)'' and 
     inserting ``(H), and (I)''; and
       (2) by adding at the end the following new subparagraph:
       ``(I) Floor for practice expense index for services 
     furnished in frontier states.--
       ``(i) In general.--Subject to clause (ii), for purposes of 
     payment for services furnished in a frontier State (as 
     defined in section 1886(d)(3)(E)(iii)(II)) on or after 
     January 1, 2011, after calculating the practice expense index 
     in subparagraph (A)(i), the Secretary shall increase any such 
     index to 1.00 if such index would otherwise be less that 
     1.00. The preceding sentence shall not be applied in a budget 
     neutral manner.
       ``(ii) Limitation.--This subparagraph shall not apply to 
     services furnished in a State that receives a non-labor 
     related share adjustment under section 1886(d)(5)(H).''.

     SEC. 10325. REVISION TO SKILLED NURSING FACILITY PROSPECTIVE 
                   PAYMENT SYSTEM.

       (a) Temporary Delay of RUG-IV.--Notwithstanding any other 
     provision of law, the Secretary of Health and Human Services 
     shall not, prior to October 1, 2011, implement Version 4 of 
     the Resource Utilization Groups (in this subsection refereed 
     to as ``RUG-IV'') published in the Federal Register on August 
     11, 2009, entitled ``Prospective Payment System and 
     Consolidated Billing for Skilled Nursing Facilities for FY 
     2010; Minimum Data Set, Version 3.0 for Skilled Nursing 
     Facilities and Medicaid Nursing Facilities'' (74 Fed. Reg. 
     40288). Beginning on October 1, 2010, the Secretary of Health 
     and Human Services shall implement the change specific to 
     therapy furnished on a concurrent basis that is a component 
     of RUG-IV and changes to the lookback period to ensure that 
     only those services furnished after admission to a skilled 
     nursing facility are used as factors in determining a case 
     mix classification under the skilled nursing facility 
     prospective payment system under section 1888(e) of the 
     Social Security Act (42 U.S.C. 1395yy(e)).
       (b) Construction.--Nothing in this section shall be 
     interpreted as delaying the implementation of Version 3.0 of 
     the Minimum Data Sets (MDS 3.0) beyond the planned 
     implementation date of October 1, 2010.

     SEC. 10326. PILOT TESTING PAY-FOR-PERFORMANCE PROGRAMS FOR 
                   CERTAIN MEDICARE PROVIDERS.

       (a) In General.--Not later than January 1, 2016, the 
     Secretary of Health and Human Services (in this section 
     referred to as the ``Secretary'') shall, for each provider 
     described in subsection (b), conduct a separate pilot program 
     under title XVIII of the Social Security Act to test the 
     implementation of a value-based purchasing program for 
     payments under such title for the provider.
       (b) Providers Described.--The providers described in this 
     paragraph are the following:
       (1) Psychiatric hospitals (as described in clause (i) of 
     section 1886(d)(1)(B) of such Act (42 U.S.C. 
     1395ww(d)(1)(B))) and psychiatric units (as described in the 
     matter following clause (v) of such section).
       (2) Long-term care hospitals (as described in clause (iv) 
     of such section).
       (3) Rehabilitation hospitals (as described in clause (ii) 
     of such section).
       (4) PPS-exempt cancer hospitals (as described in clause (v) 
     of such section).
       (5) Hospice programs (as defined in section 1861(dd)(2) of 
     such Act (42 U.S.C. 1395x(dd)(2))).
       (c) Waiver Authority.--The Secretary may waive such 
     requirements of titles XI and XVIII of the Social Security 
     Act as may be necessary solely for purposes of carrying out 
     the pilot programs under this section.
       (d) No Additional Program Expenditures.--Payments under 
     this section under the separate pilot program for value based 
     purchasing (as described in subsection (a)) for each provider 
     type described in paragraphs (1) through (5) of subsection 
     (b) for applicable items and services under title XVIII of 
     the Social Security Act for a year shall be established in a 
     manner that does not result in spending more under each such 
     value based purchasing program for such year than would 
     otherwise be expended for such provider type for such year if 
     the pilot program were not implemented, as estimated by the 
     Secretary.
       (e) Expansion of Pilot Program.--The Secretary may, at any 
     point after January 1, 2018, expand the duration and scope of 
     a pilot program conducted under this subsection, to the 
     extent determined appropriate by the Secretary, if--
       (1) the Secretary determines that such expansion is 
     expected to--
       (A) reduce spending under title XVIII of the Social 
     Security Act without reducing the quality of care; or
       (B) improve the quality of care and reduce spending;
       (2) the Chief Actuary of the Centers for Medicare & 
     Medicaid Services certifies that such expansion would reduce 
     program spending under such title XVIII; and
       (3) the Secretary determines that such expansion would not 
     deny or limit the coverage or provision of benefits under 
     such title XIII for Medicare beneficiaries.

     SEC. 10327. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING 
                   SYSTEM.

       (a) In General.--Section 1848(m) of the Social Security Act 
     (42 U.S.C. 1395w-4(m)) is amended by adding at the end the 
     following new paragraph:
       ``(7) Additional incentive payment.--
       ``(A) In general.--For 2011 through 2014, if an eligible 
     professional meets the requirements described in subparagraph 
     (B), the applicable quality percent for such year, as 
     described in clauses (iii) and (iv) of paragraph (1)(B), 
     shall be increased by 0.5 percentage points.
       ``(B) Requirements described.--In order to qualify for the 
     additional incentive payment described in subparagraph (A), 
     an eligible professional shall meet the following 
     requirements:
       ``(i) The eligible professional shall--

       ``(I) satisfactorily submit data on quality measures for 
     purposes of paragraph (1) for a year; and
       ``(II) have such data submitted on their behalf through a 
     Maintenance of Certification Program (as defined in 
     subparagraph (C)(i)) that meets--

       ``(aa) the criteria for a registry (as described in 
     subsection (k)(4)); or

[[Page 32774]]

       ``(bb) an alternative form and manner determined 
     appropriate by the Secretary.
       ``(ii) The eligible professional, more frequently than is 
     required to qualify for or maintain board certification 
     status--

       ``(I) participates in such a Maintenance of Certification 
     program for a year; and
       ``(II) successfully completes a qualified Maintenance of 
     Certification Program practice assessment (as defined in 
     subparagraph (C)(ii)) for such year.

       ``(iii) A Maintenance of Certification program submits to 
     the Secretary, on behalf of the eligible professional, 
     information--

       ``(I) in a form and manner specified by the Secretary, that 
     the eligible professional has successfully met the 
     requirements of clause (ii) (which may be in the form of a 
     structural measure);
       ``(II) if requested by the Secretary, on the survey of 
     patient experience with care (as described in subparagraph 
     (C)(ii)(II)); and
       ``(III) as the Secretary may require, on the methods, 
     measures, and data used under the Maintenance of 
     Certification Program and the qualified Maintenance of 
     Certification Program practice assessment.

       ``(C) Definitions.--For purposes of this paragraph:
       ``(i) The term `Maintenance of Certification Program' means 
     a continuous assessment program, such as qualified American 
     Board of Medical Specialties Maintenance of Certification 
     program or an equivalent program (as determined by the 
     Secretary), that advances quality and the lifelong learning 
     and self-assessment of board certified specialty physicians 
     by focusing on the competencies of patient care, medical 
     knowledge, practice-based learning, interpersonal and 
     communication skills and professionalism. Such a program 
     shall include the following:

       ``(I) The program requires the physician to maintain a 
     valid, unrestricted medical license in the United States.
       ``(II) The program requires a physician to participate in 
     educational and self-assessment programs that require an 
     assessment of what was learned.
       ``(III) The program requires a physician to demonstrate, 
     through a formalized, secure examination, that the physician 
     has the fundamental diagnostic skills, medical knowledge, and 
     clinical judgment to provide quality care in their respective 
     specialty.
       ``(IV) The program requires successful completion of a 
     qualified Maintenance of Certification Program practice 
     assessment as described in clause (ii).

       ``(ii) The term `qualified Maintenance of Certification 
     Program practice assessment' means an assessment of a 
     physician's practice that--

       ``(I) includes an initial assessment of an eligible 
     professional's practice that is designed to demonstrate the 
     physician's use of evidence-based medicine;
       ``(II) includes a survey of patient experience with care; 
     and
       ``(III) requires a physician to implement a quality 
     improvement intervention to address a practice weakness 
     identified in the initial assessment under subclause (I) and 
     then to remeasure to assess performance improvement after 
     such intervention.''.

       (b) Authority.--Section 3002(c) of this Act is amended by 
     adding at the end the following new paragraph:
       ``(3) Authority.--For years after 2014, if the Secretary of 
     Health and Human Services determines it to be appropriate, 
     the Secretary may incorporate participation in a Maintenance 
     of Certification Program and successful completion of a 
     qualified Maintenance of Certification Program practice 
     assessment into the composite of measures of quality of care 
     furnished pursuant to the physician fee schedule payment 
     modifier, as described in section 1848(p)(2) of the Social 
     Security Act (42 U.S.C. 1395w-4(p)(2)).''.
       (c) Elimination of MA Regional Plan Stabilization Fund.--
       (1) In general.--Section 1858 of the Social Security Act 
     (42 U.S.C. 1395w-27a) is amended by striking subsection (e).
       (2) Transition.--Any amount contained in the MA Regional 
     Plan Stabilization Fund as of the date of the enactment of 
     this Act shall be transferred to the Federal Supplementary 
     Medical Insurance Trust Fund.

     SEC. 10328. IMPROVEMENT IN PART D MEDICATION THERAPY 
                   MANAGEMENT (MTM) PROGRAMS.

       (a) In General.--Section 1860D-4(c)(2) of the Social 
     Security Act (42 U.S.C. 1395w-104(c)(2)) is amended--
       (1) by redesignating subparagraphs (C), (D), and (E) as 
     subparagraphs (E), (F), and (G), respectively; and
       (2) by inserting after subparagraph (B) the following new 
     subparagraphs:
       ``(C) Required interventions.--For plan years beginning on 
     or after the date that is 2 years after the date of the 
     enactment of the Patient Protection and Affordable Care Act, 
     prescription drug plan sponsors shall offer medication 
     therapy management services to targeted beneficiaries 
     described in subparagraph (A)(ii) that include, at a minimum, 
     the following to increase adherence to prescription 
     medications or other goals deemed necessary by the Secretary:
       ``(i) An annual comprehensive medication review furnished 
     person-to-person or using telehealth technologies (as defined 
     by the Secretary) by a licensed pharmacist or other qualified 
     provider. The comprehensive medication review--

       ``(I) shall include a review of the individual's 
     medications and may result in the creation of a recommended 
     medication action plan or other actions in consultation with 
     the individual and with input from the prescriber to the 
     extent necessary and practicable; and
       ``(II) shall include providing the individual with a 
     written or printed summary of the results of the review.

     The Secretary, in consultation with relevant stakeholders, 
     shall develop a standardized format for the action plan under 
     subclause (I) and the summary under subclause (II).
       ``(ii) Follow-up interventions as warranted based on the 
     findings of the annual medication review or the targeted 
     medication enrollment and which may be provided person-to-
     person or using telehealth technologies (as defined by the 
     Secretary).
       ``(D) Assessment.--The prescription drug plan sponsor shall 
     have in place a process to assess, at least on a quarterly 
     basis, the medication use of individuals who are at risk but 
     not enrolled in the medication therapy management program, 
     including individuals who have experienced a transition in 
     care, if the prescription drug plan sponsor has access to 
     that information.
       ``(E) Automatic enrollment with ability to opt-out.--The 
     prescription drug plan sponsor shall have in place a process 
     to--
       ``(i) subject to clause (ii), automatically enroll targeted 
     beneficiaries described in subparagraph (A)(ii), including 
     beneficiaries identified under subparagraph (D), in the 
     medication therapy management program required under this 
     subsection; and
       ``(ii) permit such beneficiaries to opt-out of enrollment 
     in such program.''.
       (b) Rule of Construction.--Nothing in this section shall 
     limit the authority of the Secretary of Health and Human 
     Services to modify or broaden requirements for a medication 
     therapy management program under part D of title XVIII of the 
     Social Security Act or to study new models for medication 
     therapy management through the Center for Medicare and 
     Medicaid Innovation under section 1115A of such Act, as added 
     by section 3021.

     SEC. 10329. DEVELOPING METHODOLOGY TO ASSESS HEALTH PLAN 
                   VALUE.

       (a) Development.--The Secretary of Health and Human 
     Services (referred to in this section as the ``Secretary''), 
     in consultation with relevant stakeholders including health 
     insurance issuers, health care consumers, employers, health 
     care providers, and other entities determined appropriate by 
     the Secretary, shall develop a methodology to measure health 
     plan value. Such methodology shall take into consideration, 
     where applicable--
       (1) the overall cost to enrollees under the plan;
       (2) the quality of the care provided for under the plan;
       (3) the efficiency of the plan in providing care;
       (4) the relative risk of the plan's enrollees as compared 
     to other plans;
       (5) the actuarial value or other comparative measure of the 
     benefits covered under the plan; and
       (6) other factors determined relevant by the Secretary.
       (b) Report.--Not later than 18 months after the date of 
     enactment of this Act, the Secretary shall submit to Congress 
     a report concerning the methodology developed under 
     subsection (a).

     SEC. 10330. MODERNIZING COMPUTER AND DATA SYSTEMS OF THE 
                   CENTERS FOR MEDICARE & MEDICAID SERVICES TO 
                   SUPPORT IMPROVEMENTS IN CARE DELIVERY.

       (a) In General.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     develop a plan (and detailed budget for the resources needed 
     to implement such plan) to modernize the computer and data 
     systems of the Centers for Medicare & Medicaid Services (in 
     this section referred to as ``CMS'').
       (b) Considerations.--In developing the plan, the Secretary 
     shall consider how such modernized computer system could--
       (1) in accordance with the regulations promulgated under 
     section 264(c) of the Health Insurance Portability and 
     Accountability Act of 1996, make available data in a reliable 
     and timely manner to providers of services and suppliers to 
     support their efforts to better manage and coordinate care 
     furnished to beneficiaries of CMS programs; and
       (2) support consistent evaluations of payment and delivery 
     system reforms under CMS programs.
       (c) Posting of Plan.--By not later than 9 months after the 
     date of the enactment of this Act, the Secretary shall post 
     on the website of the Centers for Medicare & Medicaid 
     Services the plan described in subsection (a).

     SEC. 10331. PUBLIC REPORTING OF PERFORMANCE INFORMATION.

       (a) In General.--
       (1) Development.--Not later than January 1, 2011, the 
     Secretary shall develop a Physician Compare Internet website 
     with information on physicians enrolled in the Medicare 
     program under section 1866(j) of the Social Security Act (42 
     U.S.C. 1395cc(j)) and other

[[Page 32775]]

     eligible professionals who participate in the Physician 
     Quality Reporting Initiative under section 1848 of such Act 
     (42 U.S.C. 1395w-4).
       (2) Plan.--Not later than January 1, 2013, and with respect 
     to reporting periods that begin no earlier than January 1, 
     2012, the Secretary shall also implement a plan for making 
     publicly available through Physician Compare, consistent with 
     subsection (c), information on physician performance that 
     provides comparable information for the public on quality and 
     patient experience measures with respect to physicians 
     enrolled in the Medicare program under such section 1866(j). 
     To the extent scientifically sound measures that are 
     developed consistent with the requirements of this section 
     are available, such information, to the extent practicable, 
     shall include--
       (A) measures collected under the Physician Quality 
     Reporting Initiative;
       (B) an assessment of patient health outcomes and the 
     functional status of patients;
       (C) an assessment of the continuity and coordination of 
     care and care transitions, including episodes of care and 
     risk-adjusted resource use;
       (D) an assessment of efficiency;
       (E) an assessment of patient experience and patient, 
     caregiver, and family engagement;
       (F) an assessment of the safety, effectiveness, and 
     timeliness of care; and
       (G) other information as determined appropriate by the 
     Secretary.
       (b) Other Required Considerations.--In developing and 
     implementing the plan described in subsection (a)(2), the 
     Secretary shall, to the extent practicable, include--
       (1) processes to assure that data made public, either by 
     the Centers for Medicare & Medicaid Services or by other 
     entities, is statistically valid and reliable, including risk 
     adjustment mechanisms used by the Secretary;
       (2) processes by which a physician or other eligible 
     professional whose performance on measures is being publicly 
     reported has a reasonable opportunity, as determined by the 
     Secretary, to review his or her individual results before 
     they are made public;
       (3) processes by the Secretary to assure that the 
     implementation of the plan and the data made available on 
     Physician Compare provide a robust and accurate portrayal of 
     a physician's performance;
       (4) data that reflects the care provided to all patients 
     seen by physicians, under both the Medicare program and, to 
     the extent practicable, other payers, to the extent such 
     information would provide a more accurate portrayal of 
     physician performance;
       (5) processes to ensure appropriate attribution of care 
     when multiple physicians and other providers are involved in 
     the care of a patient;
       (6) processes to ensure timely statistical performance 
     feedback is provided to physicians concerning the data 
     reported under any program subject to public reporting under 
     this section; and
       (7) implementation of computer and data systems of the 
     Centers for Medicare & Medicaid Services that support valid, 
     reliable, and accurate public reporting activities authorized 
     under this section.
       (c) Ensuring Patient Privacy.--The Secretary shall ensure 
     that information on physician performance and patient 
     experience is not disclosed under this section in a manner 
     that violates sections 552 or 552a of title 5, United States 
     Code, with regard to the privacy of individually identifiable 
     health information.
       (d) Feedback From Multi-Stakeholder Groups.--The Secretary 
     shall take into consideration input provided by multi-
     stakeholder groups, consistent with sections 1890(b)(7) and 
     1890A of the Social Security Act, as added by section 3014 of 
     this Act, in selecting quality measures for use under this 
     section.
       (e) Consideration of Transition to Value-Based 
     Purchasing.--In developing the plan under this subsection 
     (a)(2), the Secretary shall, as the Secretary determines 
     appropriate, consider the plan to transition to a value-based 
     purchasing program for physicians and other practitioners 
     developed under section 131 of the Medicare Improvements for 
     Patients and Providers Act of 2008 (Public Law 110-275).
       (f) Report to Congress.--Not later than January 1, 2015, 
     the Secretary shall submit to Congress a report on the 
     Physician Compare Internet website developed under subsection 
     (a)(1). Such report shall include information on the efforts 
     of and plans made by the Secretary to collect and publish 
     data on physician quality and efficiency and on patient 
     experience of care in support of value-based purchasing and 
     consumer choice, together with recommendations for such 
     legislation and administrative action as the Secretary 
     determines appropriate.
       (g) Expansion.--At any time before the date on which the 
     report is submitted under subsection (f), the Secretary may 
     expand (including expansion to other providers of services 
     and suppliers under title XVIII of the Social Security Act) 
     the information made available on such website.
       (h) Financial Incentives to Encourage Consumers to Choose 
     High Quality Providers.--The Secretary may establish a 
     demonstration program, not later than January 1, 2019, to 
     provide financial incentives to Medicare beneficiaries who 
     are furnished services by high quality physicians, as 
     determined by the Secretary based on factors in subparagraphs 
     (A) through (G) of subsection (a)(2). In no case may Medicare 
     beneficiaries be required to pay increased premiums or cost 
     sharing or be subject to a reduction in benefits under title 
     XVIII of the Social Security Act as a result of such 
     demonstration program. The Secretary shall ensure that any 
     such demonstration program does not disadvantage those 
     beneficiaries without reasonable access to high performing 
     physicians or create financial inequities under such title.
       (i) Definitions.--In this section:
       (1) Eligible professional.--The term ``eligible 
     professional'' has the meaning given that term for purposes 
     of the Physician Quality Reporting Initiative under section 
     1848 of the Social Security Act (42 U.S.C. 1395w-4)
       (2) Physician.--The term ``physician'' has the meaning 
     given that term in section 1861(r) of such Act (42 U.S.C. 
     1395x(r)).
       (3) Physician compare.--The term ``Physician Compare'' 
     means the Internet website developed under subsection (a)(1).
       (4) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.

     SEC. 10332. AVAILABILITY OF MEDICARE DATA FOR PERFORMANCE 
                   MEASUREMENT.

       (a) In General.--Section 1874 of the Social Security Act 
     (42 U.S.C. 1395kk) is amended by adding at the end the 
     following new subsection:
       ``(e) Availability of Medicare Data.--
       ``(1) In general.--Subject to paragraph (4), the Secretary 
     shall make available to qualified entities (as defined in 
     paragraph (2)) data described in paragraph (3) for the 
     evaluation of the performance of providers of services and 
     suppliers.
       ``(2) Qualified entities.--For purposes of this subsection, 
     the term `qualified entity' means a public or private entity 
     that--
       ``(A) is qualified (as determined by the Secretary) to use 
     claims data to evaluate the performance of providers of 
     services and suppliers on measures of quality, efficiency, 
     effectiveness, and resource use; and
       ``(B) agrees to meet the requirements described in 
     paragraph (4) and meets such other requirements as the 
     Secretary may specify, such as ensuring security of data.
       ``(3) Data described.--The data described in this paragraph 
     are standardized extracts (as determined by the Secretary) of 
     claims data under parts A, B, and D for items and services 
     furnished under such parts for one or more specified 
     geographic areas and time periods requested by a qualified 
     entity. The Secretary shall take such actions as the 
     Secretary deems necessary to protect the identity of 
     individuals entitled to or enrolled for benefits under such 
     parts.
       ``(4) Requirements.--
       ``(A) Fee.--Data described in paragraph (3) shall be made 
     available to a qualified entity under this subsection at a 
     fee equal to the cost of making such data available. Any fee 
     collected pursuant to the preceding sentence shall be 
     deposited into the Federal Supplementary Medical Insurance 
     Trust Fund under section 1841.
       ``(B) Specification of uses and methodologies.--A qualified 
     entity requesting data under this subsection shall--
       ``(i) submit to the Secretary a description of the 
     methodologies that such qualified entity will use to evaluate 
     the performance of providers of services and suppliers using 
     such data;
       ``(ii)(I) except as provided in subclause (II), if 
     available, use standard measures, such as measures endorsed 
     by the entity with a contract under section 1890(a) and 
     measures developed pursuant to section 931 of the Public 
     Health Service Act; or
       ``(II) use alternative measures if the Secretary, in 
     consultation with appropriate stakeholders, determines that 
     use of such alternative measures would be more valid, 
     reliable, responsive to consumer preferences, cost-effective, 
     or relevant to dimensions of quality and resource use not 
     addressed by such standard measures;
       ``(iii) include data made available under this subsection 
     with claims data from sources other than claims data under 
     this title in the evaluation of performance of providers of 
     services and suppliers;
       ``(iv) only include information on the evaluation of 
     performance of providers and suppliers in reports described 
     in subparagraph (C);
       ``(v) make available to providers of services and 
     suppliers, upon their request, data made available under this 
     subsection; and
       ``(vi) prior to their release, submit to the Secretary the 
     format of reports under subparagraph (C).
       ``(C) Reports.--Any report by a qualified entity evaluating 
     the performance of providers of services and suppliers using 
     data made available under this subsection shall--
       ``(i) include an understandable description of the 
     measures, which shall include quality measures and the 
     rationale for use of other measures described in subparagraph 
     (B)(ii)(II), risk adjustment methods, physician attribution 
     methods, other applicable methods, data specifications and 
     limitations, and the sponsors, so that consumers, providers 
     of services and suppliers, health plans,

[[Page 32776]]

     researchers, and other stakeholders can assess such reports;
       ``(ii) be made available confidentially, to any provider of 
     services or supplier to be identified in such report, prior 
     to the public release of such report, and provide an 
     opportunity to appeal and correct errors;
       ``(iii) only include information on a provider of services 
     or supplier in an aggregate form as determined appropriate by 
     the Secretary; and
       ``(iv) except as described in clause (ii), be made 
     available to the public.
       ``(D) Approval and limitation of uses.--The Secretary shall 
     not make data described in paragraph (3) available to a 
     qualified entity unless the qualified entity agrees to 
     release the information on the evaluation of performance of 
     providers of services and suppliers. Such entity shall only 
     use such data, and information derived from such evaluation, 
     for the reports under subparagraph (C). Data released to a 
     qualified entity under this subsection shall not be subject 
     to discovery or admission as evidence in judicial or 
     administrative proceedings without consent of the applicable 
     provider of services or supplier.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall take effect on January 1, 2012.

     SEC. 10333. COMMUNITY-BASED COLLABORATIVE CARE NETWORKS.

       Part D of title III of the Public Health Service Act (42 
     U.S.C. 254b et seq.) is amended by adding at the end the 
     following new subpart:

    ``Subpart XI--Community-Based Collaborative Care Network Program

     ``SEC. 340H. COMMUNITY-BASED COLLABORATIVE CARE NETWORK 
                   PROGRAM.

       ``(a) In General.--The Secretary may award grants to 
     eligible entities to support community-based collaborative 
     care networks that meet the requirements of subsection (b).
       ``(b) Community-Based Collaborative Care Networks.--
       ``(1) Description.--A community-based collaborative care 
     network (referred to in this section as a `network') shall be 
     a consortium of health care providers with a joint governance 
     structure (including providers within a single entity) that 
     provides comprehensive coordinated and integrated health care 
     services (as defined by the Secretary) for low-income 
     populations.
       ``(2) Required inclusion.--A network shall include the 
     following providers (unless such provider does not exist 
     within the community, declines or refuses to participate, or 
     places unreasonable conditions on their participation):
       ``(A) A hospital that meets the criteria in section 
     1923(b)(1) of the Social Security Act; and
       ``(B) All Federally qualified health centers (as defined in 
     section 1861(aa) of the Social Security Act located in the 
     community.
       ``(3) Priority.--In awarding grants, the Secretary shall 
     give priority to networks that include--
       ``(A) the capability to provide the broadest range of 
     services to low-income individuals;
       ``(B) the broadest range of providers that currently serve 
     a high volume of low-income individuals; and
       ``(C) a county or municipal department of health.
       ``(c) Application.--
       ``(1) Application.--A network described in subsection (b) 
     shall submit an application to the Secretary.
       ``(2) Renewal.--In subsequent years, based on the 
     performance of grantees, the Secretary may provide renewal 
     grants to prior year grant recipients.
       ``(d) Use of Funds.--
       ``(1) Use by grantees.--Grant funds may be used for the 
     following activities:
       ``(A) Assist low-income individuals to--
       ``(i) access and appropriately use health services;
       ``(ii) enroll in health coverage programs; and
       ``(iii) obtain a regular primary care provider or a medical 
     home.
       ``(B) Provide case management and care management.
       ``(C) Perform health outreach using neighborhood health 
     workers or through other means.
       ``(D) Provide transportation.
       ``(E) Expand capacity, including through telehealth, after-
     hours services or urgent care.
       ``(F) Provide direct patient care services.
       ``(2) Grant funds to hrsa grantees.--The Secretary may 
     limit the percent of grant funding that may be spent on 
     direct care services provided by grantees of programs 
     administered by the Health Resources and Services 
     Administration or impose other requirements on such grantees 
     deemed necessary.
       ``(e) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section such 
     sums as may be necessary for each of fiscal years 2011 
     through 2015.''.

     SEC. 10334. MINORITY HEALTH.

       (a) Office of Minority Health.--
       (1) In general.--Section 1707 of the Public Health Service 
     Act (42 U.S.C. 300u-6) is amended--
       (A) in subsection (a), by striking ``within the Office of 
     Public Health and Science'' and all that follows through the 
     end and inserting ``. The Office of Minority Health as 
     existing on the date of enactment of the Patient Protection 
     and Affordable Care Act shall be transferred to the Office of 
     the Secretary in such manner that there is established in the 
     Office of the Secretary, the Office of Minority Health, which 
     shall be headed by the Deputy Assistant Secretary for 
     Minority Health who shall report directly to the Secretary, 
     and shall retain and strengthen authorities (as in existence 
     on such date of enactment) for the purpose of improving 
     minority health and the quality of health care minorities 
     receive, and eliminating racial and ethnic disparities. In 
     carrying out this subsection, the Secretary, acting through 
     the Deputy Assistant Secretary, shall award grants, 
     contracts, enter into memoranda of understanding, 
     cooperative, interagency, intra-agency and other agreements 
     with public and nonprofit private entities, agencies, as well 
     as Departmental and Cabinet agencies and organizations, and 
     with organizations that are indigenous human resource 
     providers in communities of color to assure improved health 
     status of racial and ethnic minorities, and shall develop 
     measures to evaluate the effectiveness of activities aimed at 
     reducing health disparities and supporting the local 
     community. Such measures shall evaluate community outreach 
     activities, language services, workforce cultural competence, 
     and other areas as determined by the Secretary.''; and
       (B) by striking subsection (h) and inserting the following:
       ``(h) Authorization of Appropriations.--For the purpose of 
     carrying out this section, there are authorized to be 
     appropriated such sums as may be necessary for each of fiscal 
     years 2011 through 2016.''.
       (2) Transfer of functions.--There are transferred to the 
     Office of Minority Health in the office of the Secretary of 
     Health and Human Services, all duties, responsibilities, 
     authorities, accountabilities, functions, staff, funds, award 
     mechanisms, and other entities under the authority of the 
     Office of Minority Health of the Public Health Service as in 
     effect on the date before the date of enactment of this Act, 
     which shall continue in effect according to the terms in 
     effect on the date before such date of enactment, until 
     modified, terminated, superseded, set aside, or revoked in 
     accordance with law by the President, the Secretary, a court 
     of competent jurisdiction, or by operation of law.
       (3) Reports.--Not later than 1 year after the date of 
     enactment of this section, and biennially thereafter, the 
     Secretary of Health and Human Services shall prepare and 
     submit to the appropriate committees of Congress a report 
     describing the activities carried out under section 1707 of 
     the Public Health Service Act (as amended by this subsection) 
     during the period for which the report is being prepared. Not 
     later than 1 year after the date of enactment of this 
     section, and biennially thereafter, the heads of each of the 
     agencies of the Department of Health and Human Services shall 
     submit to the Deputy Assistant Secretary for Minority Health 
     a report summarizing the minority health activities of each 
     of the respective agencies.
       (b) Establishment of Individual Offices of Minority Health 
     Within the Department of Health and Human Services.--
       (1) In general.--Title XVII of the Public Health Service 
     Act (42 U.S.C. 300u et seq.) is amended by inserting after 
     section 1707 the following section:

     ``SEC. 1707A. INDIVIDUAL OFFICES OF MINORITY HEALTH WITHIN 
                   THE DEPARTMENT.

       ``(a) In General.--The head of each agency specified in 
     subsection (b)(1) shall establish within the agency an office 
     to be known as the Office of Minority Health. The head of 
     each such Office shall be appointed by the head of the agency 
     within which the Office is established, and shall report 
     directly to the head of the agency. The head of such agency 
     shall carry out this section (as this section relates to the 
     agency) acting through such Director.
       ``(b) Specified Agencies.--The agencies referred to in 
     subsection (a) are the Centers for Disease Control and 
     Prevention, the Health Resources and Services Administration, 
     the Substance Abuse and Mental Health Services 
     Administration, the Agency for Healthcare Research and 
     Quality, the Food and Drug Administration, and the Centers 
     for Medicare & Medicaid Services.
       ``(c) Director; Appointment.--Each Office of Minority 
     Health established in an agency listed in subsection (a) 
     shall be headed by a director, with documented experience and 
     expertise in minority health services research and health 
     disparities elimination.
       ``(d) References.--Except as otherwise specified, any 
     reference in Federal law to an Office of Minority Health (in 
     the Department of Health and Human Services) is deemed to be 
     a reference to the Office of Minority Health in the Office of 
     the Secretary.
       ``(e) Funding.--
       ``(1) Allocations.--Of the amounts appropriated for a 
     specified agency for a fiscal year, the Secretary must 
     designate an appropriate amount of funds for the purpose of 
     carrying out activities under this section through the 
     minority health office of the agency. In reserving an amount 
     under the preceding sentence for a minority health office for 
     a fiscal year, the Secretary shall reduce, by substantially 
     the same percentage,

[[Page 32777]]

     the amount that otherwise would be available for each of the 
     programs of the designated agency involved.
       ``(2) Availability of funds for staffing.--The purposes for 
     which amounts made available under paragraph may be expended 
     by a minority health office include the costs of employing 
     staff for such office.''.
       (2) No new regulatory authority.--Nothing in this 
     subsection and the amendments made by this subsection may be 
     construed as establishing regulatory authority or modifying 
     any existing regulatory authority.
       (3) Limitation on termination.--Notwithstanding any other 
     provision of law, a Federal office of minority health or 
     Federal appointive position with primary responsibility over 
     minority health issues that is in existence in an office of 
     agency of the Department of Health and Human Services on the 
     date of enactment of this section shall not be terminated, 
     reorganized, or have any of its power or duties transferred 
     unless such termination, reorganization, or transfer is 
     approved by an Act of Congress.
       (c) Redesignation of National Center on Minority Health and 
     Health Disparities.--
       (1) Redesignation.--Title IV of the Public Health Service 
     Act (42 U.S.C. 281 et seq.) is amended--
       (A) by redesignating subpart 6 of part E as subpart 20;
       (B) by transferring subpart 20, as so redesignated, to part 
     C of such title IV;
       (C) by inserting subpart 20, as so redesignated, after 
     subpart 19 of such part C; and
       (D) in subpart 20, as so redesignated--
       (i) by redesignating sections 485E through 485H as sections 
     464z-3 through 464z-6, respectively;
       (ii) by striking ``National Center on Minority Health and 
     Health Disparities'' each place such term appears and 
     inserting ``National Institute on Minority Health and Health 
     Disparities''; and
       (iii) by striking ``Center'' each place such term appears 
     and inserting ``Institute''.
       (2) Purpose of institute; duties.--Section 464z-3 of the 
     Public Health Service Act, as so redesignated, is amended--
       (A) in subsection (h)(1), by striking ``research endowments 
     at centers of excellence under section 736.'' and inserting 
     the following: ``research endowments--
       ``(1) at centers of excellence under section 736; and
       ``(2) at centers of excellence under section 464z-4.'';
       (B) in subsection (h)(2)(A), by striking ``average'' and 
     inserting ``median''; and
       (C) by adding at the end the following:
       ``(h) Interagency Coordination.--The Director of the 
     Institute, as the primary Federal officials with 
     responsibility for coordinating all research and activities 
     conducted or supported by the National Institutes of Health 
     on minority health and health disparities, shall plan, 
     coordinate, review and evaluate research and other activities 
     conducted or supported by the Institutes and Centers of the 
     National Institutes of Health.''.
       (3) Technical and conforming amendments.--
       (A) Section 401(b)(24) of the Public Health Service Act (42 
     U.S.C. 281(b)(24)) is amended by striking ``Center'' and 
     inserting ``Institute''.
       (B) Subsection (d)(1) of section 903 of the Public Health 
     Service Act (42 U.S.C. 299a-1(d)(1)) is amended by striking 
     ``section 485E'' and inserting ``section 464z-3''.

     SEC. 10335. TECHNICAL CORRECTION TO THE HOSPITAL VALUE-BASED 
                   PURCHASING PROGRAM.

       Section 1886(o)(2)A) of the Social Security Act, as added 
     by section 3001, is amended, in the first sentence, by 
     inserting ``, other than measures of readmissions,'' after 
     ``shall select measures''.

     SEC. 10336. GAO STUDY AND REPORT ON MEDICARE BENEFICIARY 
                   ACCESS TO HIGH-QUALITY DIALYSIS SERVICES.

       (a) Study.--
       (1) In general.--The Comptroller General of the United 
     States shall conduct a study on the impact on Medicare 
     beneficiary access to high-quality dialysis services of 
     including specified oral drugs that are furnished to such 
     beneficiaries for the treatment of end stage renal disease in 
     the bundled prospective payment system under section 
     1881(b)(14) of the Social Security Act (42 U.S.C. 
     1395rr(b)(14)) (pursuant to the proposed rule published by 
     the Secretary of Health and Human Services in the Federal 
     Register on September 29, 2009 (74 Fed. Reg. 49922 et seq.)). 
     Such study shall include an analysis of--
       (A) the ability of providers of services and renal dialysis 
     facilities to furnish specified oral drugs or arrange for the 
     provision of such drugs;
       (B) the ability of providers of services and renal dialysis 
     facilities to comply, if necessary, with applicable State 
     laws (such as State pharmacy licensure requirements) in order 
     to furnish specified oral drugs;
       (C) whether appropriate quality measures exist to safeguard 
     care for Medicare beneficiaries being furnished specified 
     oral drugs by providers of services and renal dialysis 
     facilities; and
       (D) other areas determined appropriate by the Comptroller 
     General.
       (2) Specified oral drug defined.--For purposes of paragraph 
     (1), the term ``specified oral drug'' means a drug or 
     biological for which there is no injectable equivalent (or 
     other non-oral form of administration).
       (b) Report.--Not later than 1 year after the date of the 
     enactment of this Act, the Comptroller General of the United 
     States shall submit to Congress a report containing the 
     results of the study conducted under subsection (a), together 
     with recommendations for such legislation and administrative 
     action as the Comptroller General determines appropriate.

              Subtitle D--Provisions Relating to Title IV

     SEC. 10401. AMENDMENTS TO SUBTITLE A.

       (a) Section 4001(h)(4) and (5) of this Act is amended by 
     striking ``2010'' each place such appears and inserting 
     ``2020''.
       (b) Section 4002(c) of this Act is amended--
       (1) by striking ``research and health screenings'' and 
     inserting ``research, health screenings, and initiatives''; 
     and
       (2) by striking ``for Preventive'' and inserting 
     ``Regarding Preventive''.
       (c) Section 4004(a)(4) of this Act is amended by striking 
     ``a Gateway'' and inserting ``an Exchange''.

     SEC. 10402. AMENDMENTS TO SUBTITLE B.

       (a) Section 399Z-1(a)(1(A) of the Public Health Service 
     Act, as added by section 4101(b) of this Act, is amended by 
     inserting ``and vision'' after ``oral''.
       (b) Section 1861(hhh)(4)(G) of the Social Security Act, as 
     added by section 4103(b), is amended to read as follows:
       ``(G) A beneficiary shall be eligible to receive only an 
     initial preventive physical examination (as defined under 
     subsection (ww)(1)) during the 12-month period after the date 
     that the beneficiary's coverage begins under part B and shall 
     be eligible to receive personalized prevention plan services 
     under this subsection each year thereafter provided that the 
     beneficiary has not received either an initial preventive 
     physical examination or personalized prevention plan services 
     within the preceding 12-month period.''.

     SEC. 10403. AMENDMENTS TO SUBTITLE C.

       Section 4201 of this Act is amended--
       (1) in subsection (a), by adding before the period the 
     following: ``, with not less than 20 percent of such grants 
     being awarded to rural and frontier areas'';
       (2) in subsection (c)(2)(B)(vii), by striking ``both urban 
     and rural areas'' and inserting ``urban, rural, and frontier 
     areas''; and
       (3) in subsection (f), by striking ``each fiscal years'' 
     and inserting ``each of fiscal year''.

     SEC. 10404. AMENDMENTS TO SUBTITLE D.

       Section 399MM(2) of the Public Health Service Act, as added 
     by section 4303 of this Act, is amended by striking ``by 
     ensuring'' and inserting ``and ensuring''.

     SEC. 10405. AMENDMENTS TO SUBTITLE E.

       Subtitle E of title IV of this Act is amended by striking 
     section 4401.

     SEC. 10406. AMENDMENT RELATING TO WAIVING COINSURANCE FOR 
                   PREVENTIVE SERVICES.

       Section 4104(b) of this Act is amended to read as follows:
       ``(b) Payment and Elimination of Coinsurance in All 
     Settings.--Section 1833(a)(1) of the Social Security Act (42 
     U.S.C. 1395l(a)(1)), as amended by section 4103(c)(1), is 
     amended--
       ``(1) in subparagraph (T), by inserting `(or 100 percent if 
     such services are recommended with a grade of A or B by the 
     United States Preventive Services Task Force for any 
     indication or population and are appropriate for the 
     individual)' after `80 percent';
       ``(2) in subparagraph (W)--
       ``(A) in clause (i), by inserting `(if such subparagraph 
     were applied, by substituting ``100 percent'' for ``80 
     percent'')' after `subparagraph (D)'; and
       ``(B) in clause (ii), by striking `80 percent' and 
     inserting `100 percent';
       ``(3) by striking `and' before `(X)'; and
       ``(4) by inserting before the semicolon at the end the 
     following: `, and (Y) with respect to preventive services 
     described in subparagraphs (A) and (B) of section 
     1861(ddd)(3) that are appropriate for the individual and, in 
     the case of such services described in subparagraph (A), are 
     recommended with a grade of A or B by the United States 
     Preventive Services Task Force for any indication or 
     population, the amount paid shall be 100 percent of (i) 
     except as provided in clause (ii), the lesser of the actual 
     charge for the services or the amount determined under the 
     fee schedule that applies to such services under this part, 
     and (ii) in the case of such services that are covered OPD 
     services (as defined in subsection (t)(1)(B)), the amount 
     determined under subsection (t)'.''.

     SEC. 10407. BETTER DIABETES CARE.

       (a) Short Title.--This section may be cited as the 
     ``Catalyst to Better Diabetes Care Act of 2009''.
       (b) National Diabetes Report Card.--
       (1) In general.--The Secretary, in collaboration with the 
     Director of the Centers for Disease Control and Prevention 
     (referred to in this section as the ``Director''), shall 
     prepare on a biennial basis a national diabetes report card 
     (referred to in this section as a ``Report Card'') and, to 
     the extent possible, for each State.
       (2) Contents.--

[[Page 32778]]

       (A) In general.--Each Report Card shall include aggregate 
     health outcomes related to individuals diagnosed with 
     diabetes and prediabetes including--
       (i) preventative care practices and quality of care;
       (ii) risk factors; and
       (iii) outcomes.
       (B) Updated reports.--Each Report Card that is prepared 
     after the initial Report Card shall include trend analysis 
     for the Nation and, to the extent possible, for each State, 
     for the purpose of--
       (i) tracking progress in meeting established national goals 
     and objectives for improving diabetes care, costs, and 
     prevalence (including Healthy People 2010); and
       (ii) informing policy and program development.
       (3) Availability.--The Secretary, in collaboration with the 
     Director, shall make each Report Card publicly available, 
     including by posting the Report Card on the Internet.
       (c) Improvement of Vital Statistics Collection.--
       (1) In general.--The Secretary, acting through the Director 
     of the Centers for Disease Control and Prevention and in 
     collaboration with appropriate agencies and States, shall--
       (A) promote the education and training of physicians on the 
     importance of birth and death certificate data and how to 
     properly complete these documents, including the collection 
     of such data for diabetes and other chronic diseases;
       (B) encourage State adoption of the latest standard 
     revisions of birth and death certificates; and
       (C) work with States to re-engineer their vital statistics 
     systems in order to provide cost-effective, timely, and 
     accurate vital systems data.
       (2) Death certificate additional language.--In carrying out 
     this subsection, the Secretary may promote improvements to 
     the collection of diabetes mortality data, including the 
     addition of a question for the individual certifying the 
     cause of death regarding whether the deceased had diabetes.
       (d) Study on Appropriate Level of Diabetes Medical 
     Education.--
       (1) In general.--The Secretary shall, in collaboration with 
     the Institute of Medicine and appropriate associations and 
     councils, conduct a study of the impact of diabetes on the 
     practice of medicine in the United States and the 
     appropriateness of the level of diabetes medical education 
     that should be required prior to licensure, board 
     certification, and board recertification.
       (2) Report.--Not later than 2 years after the date of the 
     enactment of this Act, the Secretary shall submit a report on 
     the study under paragraph (1) to the Committees on Ways and 
     Means and Energy and Commerce of the House of Representatives 
     and the Committees on Finance and Health, Education, Labor, 
     and Pensions of the Senate.
       (e) Authorization of Appropriations.--There are authorized 
     to be appropriated to carry out this section such sums as may 
     be necessary.

     SEC. 10408. GRANTS FOR SMALL BUSINESSES TO PROVIDE 
                   COMPREHENSIVE WORKPLACE WELLNESS PROGRAMS.

       (a) Establishment.--The Secretary shall award grants to 
     eligible employers to provide their employees with access to 
     comprehensive workplace wellness programs (as described under 
     subsection (c)).
       (b) Scope.--
       (1) Duration.--The grant program established under this 
     section shall be conducted for a 5-year period.
       (2) Eligible employer.--The term ``eligible employer'' 
     means an employer (including a non-profit employer) that--
       (A) employs less than 100 employees who work 25 hours or 
     greater per week; and
       (B) does not provide a workplace wellness program as of the 
     date of enactment of this Act.
       (c) Comprehensive Workplace Wellness Programs.--
       (1) Criteria.--The Secretary shall develop program criteria 
     for comprehensive workplace wellness programs under this 
     section that are based on and consistent with evidence-based 
     research and best practices, including research and practices 
     as provided in the Guide to Community Preventive Services, 
     the Guide to Clinical Preventive Services, and the National 
     Registry for Effective Programs.
       (2) Requirements.--A comprehensive workplace wellness 
     program shall be made available by an eligible employer to 
     all employees and include the following components:
       (A) Health awareness initiatives (including health 
     education, preventive screenings, and health risk 
     assessments).
       (B) Efforts to maximize employee engagement (including 
     mechanisms to encourage employee participation).
       (C) Initiatives to change unhealthy behaviors and lifestyle 
     choices (including counseling, seminars, online programs, and 
     self-help materials).
       (D) Supportive environment efforts (including workplace 
     policies to encourage healthy lifestyles, healthy eating, 
     increased physical activity, and improved mental health).
       (d) Application.--An eligible employer desiring to 
     participate in the grant program under this section shall 
     submit an application to the Secretary, in such manner and 
     containing such information as the Secretary may require, 
     which shall include a proposal for a comprehensive workplace 
     wellness program that meet the criteria and requirements 
     described under subsection (c).
       (e) Authorization of Appropriation.--For purposes of 
     carrying out the grant program under this section, there is 
     authorized to be appropriated $200,000,000 for the period of 
     fiscal years 2011 through 2015. Amounts appropriated pursuant 
     to this subsection shall remain available until expended.

     SEC. 10409. CURES ACCELERATION NETWORK.

       (a) Short Title.--This section may be cited as the ``Cures 
     Acceleration Network Act of 2009''.
       (b) Requirement for the Director of NIH to Establish a 
     Cures Acceleration Network.--Section 402(b) of the Public 
     Health Service Act (42 U.S.C. 282(b)) is amended--
       (1) in paragraph (22), by striking ``and'' at the end;
       (2) in paragraph (23), by striking the period and inserting 
     ``; and''; and
       (3) by inserting after paragraph (23), the following:
       ``(24) implement the Cures Acceleration Network described 
     in section 402C.''.
       (c) Accepting Gifts to Support the Cures Acceleration 
     Network.--Section 499(c)(1) of the Public Health Service Act 
     (42 U.S.C. 290b(c)(1)) is amended by adding at the end the 
     following:
       ``(E) The Cures Acceleration Network described in section 
     402C.''.
       (d) Establishment of the Cures Acceleration Network.--Part 
     A of title IV of the Public Health Service Act is amended by 
     inserting after section 402B (42 U.S.C. 282b) the following:

     ``SEC. 402C. CURES ACCELERATION NETWORK.

       ``(a) Definitions.--In this section:
       ``(1) Biological product.--The term `biological product' 
     has the meaning given such term in section 351 of the Public 
     Health Service Act.
       ``(2) Drug; device.--The terms `drug' and `device' have the 
     meanings given such terms in section 201 of the Federal Food, 
     Drug, and Cosmetic Act.
       ``(3) High need cure.--The term `high need cure' means a 
     drug (as that term is defined by section 201(g)(1) of the 
     Federal Food, Drug, and Cosmetic Act, biological product (as 
     that term is defined by section 262(i)), or device (as that 
     term is defined by section 201(h) of the Federal Food, Drug, 
     and Cosmetic Act) that, in the determination of the Director 
     of NIH--
       ``(A) is a priority to diagnose, mitigate, prevent, or 
     treat harm from any disease or condition; and
       ``(B) for which the incentives of the commercial market are 
     unlikely to result in its adequate or timely development.
       ``(4) Medical product.--The term `medical product' means a 
     drug, device, biological product, or product that is a 
     combination of drugs, devices, and biological products.
       ``(b) Establishment of the Cures Acceleration Network.--
     Subject to the appropriation of funds as described in 
     subsection (g), there is established within the Office of the 
     Director of NIH a program to be known as the Cures 
     Acceleration Network (referred to in this section as `CAN'), 
     which shall--
       ``(1) be under the direction of the Director of NIH, taking 
     into account the recommendations of a CAN Review Board 
     (referred to in this section as the `Board'), described in 
     subsection (d); and
       ``(2) award grants and contracts to eligible entities, as 
     described in subsection (e), to accelerate the development of 
     high need cures, including through the development of medical 
     products and behavioral therapies.
       ``(c) Functions.--The functions of the CAN are to--
       ``(1) conduct and support revolutionary advances in basic 
     research, translating scientific discoveries from bench to 
     bedside;
       ``(2) award grants and contracts to eligible entities to 
     accelerate the development of high need cures;
       ``(3) provide the resources necessary for government 
     agencies, independent investigators, research organizations, 
     biotechnology companies, academic research institutions, and 
     other entities to develop high need cures;
       ``(4) reduce the barriers between laboratory discoveries 
     and clinical trials for new therapies; and
       ``(5) facilitate review in the Food and Drug Administration 
     for the high need cures funded by the CAN, through activities 
     that may include--
       ``(A) the facilitation of regular and ongoing communication 
     with the Food and Drug Administration regarding the status of 
     activities conducted under this section;
       ``(B) ensuring that such activities are coordinated with 
     the approval requirements of the Food and Drug 
     Administration, with the goal of expediting the development 
     and approval of countermeasures and products; and
       ``(C) connecting interested persons with additional 
     technical assistance made available under section 565 of the 
     Federal Food, Drug, and Cosmetic Act.
       ``(d) CAN Board.--

[[Page 32779]]

       ``(1) Establishment.--There is established a Cures 
     Acceleration Network Review Board (referred to in this 
     section as the `Board'), which shall advise the Director of 
     NIH on the conduct of the activities of the Cures 
     Acceleration Network.
       ``(2) Membership.--
       ``(A) In general.--
       ``(i) Appointment.--The Board shall be comprised of 24 
     members who are appointed by the Secretary and who serve at 
     the pleasure of the Secretary.
       ``(ii) Chairperson and vice chairperson.--The Secretary 
     shall designate, from among the 24 members appointed under 
     clause (i), one Chairperson of the Board (referred to in this 
     section as the `Chairperson') and one Vice Chairperson.
       ``(B) Terms.--
       ``(i) In general.--Each member shall be appointed to serve 
     a 4-year term, except that any member appointed to fill a 
     vacancy occurring prior to the expiration of the term for 
     which the member's predecessor was appointed shall be 
     appointed for the remainder of such term.
       ``(ii) Consecutive appointments; maximum terms.--A member 
     may be appointed to serve not more than 3 terms on the Board, 
     and may not serve more than 2 such terms consecutively.
       ``(C) Qualifications.--
       ``(i) In general.--The Secretary shall appoint individuals 
     to the Board based solely upon the individual's established 
     record of distinguished service in one of the areas of 
     expertise described in clause (ii). Each individual appointed 
     to the Board shall be of distinguished achievement and have a 
     broad range of disciplinary interests.
       ``(ii) Expertise.--The Secretary shall select individuals 
     based upon the following requirements:

       ``(I) For each of the fields of--

       ``(aa) basic research;
       ``(bb) medicine;
       ``(cc) biopharmaceuticals;
       ``(dd) discovery and delivery of medical products;
       ``(ee) bioinformatics and gene therapy;
       ``(ff) medical instrumentation; and
       ``(gg) regulatory review and approval of medical products,

     the Secretary shall select at least 1 individual who is 
     eminent in such fields.
       ``(II) At least 4 individuals shall be recognized leaders 
     in professional venture capital or private equity 
     organizations and have demonstrated experience in private 
     equity investing.
       ``(III) At least 8 individuals shall represent disease 
     advocacy organizations.

       ``(3) Ex-officio members.--
       ``(A) Appointment.--In addition to the 24 Board members 
     described in paragraph (2), the Secretary shall appoint as 
     ex-officio members of the Board--
       ``(i) a representative of the National Institutes of 
     Health, recommended by the Secretary of the Department of 
     Health and Human Services;
       ``(ii) a representative of the Office of the Assistant 
     Secretary of Defense for Health Affairs, recommended by the 
     Secretary of Defense;
       ``(iii) a representative of the Office of the Under 
     Secretary for Health for the Veterans Health Administration, 
     recommended by the Secretary of Veterans Affairs;
       ``(iv) a representative of the National Science Foundation, 
     recommended by the Chair of the National Science Board; and
       ``(v) a representative of the Food and Drug Administration, 
     recommended by the Commissioner of Food and Drugs.
       ``(B) Terms.--Each ex-officio member shall serve a 3-year 
     term on the Board, except that the Chairperson may adjust the 
     terms of the initial ex-officio members in order to provide 
     for a staggered term of appointment for all such members.
       ``(4) Responsibilities of the board and the director of 
     nih.--
       ``(A) Responsibilities of the board.--
       ``(i) In general.--The Board shall advise, and provide 
     recommendations to, the Director of NIH with respect to--

       ``(I) policies, programs, and procedures for carrying out 
     the duties of the Director of NIH under this section; and
       ``(II) significant barriers to successful translation of 
     basic science into clinical application (including issues 
     under the purview of other agencies and departments).

       ``(ii) Report.--In the case that the Board identifies a 
     significant barrier, as described in clause (i)(II), the 
     Board shall submit to the Secretary a report regarding such 
     barrier.
       ``(B) Responsibilities of the director of nih.--With 
     respect to each recommendation provided by the Board under 
     subparagraph (A)(i), the Director of NIH shall respond in 
     writing to the Board, indicating whether such Director will 
     implement such recommendation. In the case that the Director 
     of NIH indicates a recommendation of the Board will not be 
     implemented, such Director shall provide an explanation of 
     the reasons for not implementing such recommendation.
       ``(5) Meetings.--
       ``(A) In general.--The Board shall meet 4 times per 
     calendar year, at the call of the Chairperson.
       ``(B) Quorum; requirements; limitations.--
       ``(i) Quorum.--A quorum shall consist of a total of 13 
     members of the Board, excluding ex-officio members, with 
     diverse representation as described in clause (iii).
       ``(ii) Chairperson or vice chairperson.--Each meeting of 
     the Board shall be attended by either the Chairperson or the 
     Vice Chairperson.
       ``(iii) Diverse representation.--At each meeting of the 
     Board, there shall be not less than one scientist, one 
     representative of a disease advocacy organization, and one 
     representative of a professional venture capital or private 
     equity organization.
       ``(6) Compensation and travel expenses.--
       ``(A) Compensation.--Members shall receive compensation at 
     a rate to be fixed by the Chairperson but not to exceed a 
     rate equal to the daily equivalent of the annual rate of 
     basic pay prescribed for level IV of the Executive Schedule 
     under section 5315 of title 5, United States Code, for each 
     day (including travel time) during which the member is 
     engaged in the performance of the duties of the Board. All 
     members of the Board who are officers or employees of the 
     Untied States shall serve without compensation in addition to 
     that received for their services as officers or employees of 
     the United States.
       ``(B) Travel expenses.--Members of the Board shall be 
     allowed travel expenses, including per diem in lieu of 
     subsistence, at rates authorized for persons employed 
     intermittently by the Federal Government under section 
     5703(b) of title 5, United States Code, while away from their 
     homes or regular places of business in the performance of 
     services for the Board.
       ``(e) Grant Program.--
       ``(1) Supporting innovation.--To carry out the purposes 
     described in this section, the Director of NIH shall award 
     contracts, grants, or cooperative agreements to the entities 
     described in paragraph (2), to--
       ``(A) promote innovation in technologies supporting the 
     advanced research and development and production of high need 
     cures, including through the development of medical products 
     and behavioral therapies.
       ``(B) accelerate the development of high need cures, 
     including through the development of medical products, 
     behavioral therapies, and biomarkers that demonstrate the 
     safety or effectiveness of medical products; or
       ``(C) help the award recipient establish protocols that 
     comply with Food and Drug Administration standards and 
     otherwise permit the recipient to meet regulatory 
     requirements at all stages of development, manufacturing, 
     review, approval, and safety surveillance of a medical 
     product.
       ``(2) Eligible entities.--To receive assistance under 
     paragraph (1), an entity shall--
       ``(A) be a public or private entity, which may include a 
     private or public research institution, an institution of 
     higher education, a medical center, a biotechnology company, 
     a pharmaceutical company, a disease advocacy organization, a 
     patient advocacy organization, or an academic research 
     institution;
       ``(B) submit an application containing--
       ``(i) a detailed description of the project for which the 
     entity seeks such grant or contract;
       ``(ii) a timetable for such project;
       ``(iii) an assurance that the entity will submit--

       ``(I) interim reports describing the entity's--

       ``(aa) progress in carrying out the project; and
       ``(bb) compliance with all provisions of this section and 
     conditions of receipt of such grant or contract; and

       ``(II) a final report at the conclusion of the grant 
     period, describing the outcomes of the project; and

       ``(iv) a description of the protocols the entity will 
     follow to comply with Food and Drug Administration standards 
     and regulatory requirements at all stages of development, 
     manufacturing, review, approval, and safety surveillance of a 
     medical product; and
       ``(C) provide such additional information as the Director 
     of NIH may require.
       ``(3) Awards.--
       ``(A) The cures acceleration partnership awards.--
       ``(i) Initial award amount.--Each award under this 
     subparagraph shall be not more than $15,000,000 per project 
     for the first fiscal year for which the project is funded, 
     which shall be payable in one payment.
       ``(ii) Funding in subsequent fiscal years.--An eligible 
     entity receiving an award under clause (i) may apply for 
     additional funding for such project by submitting to the 
     Director of NIH the information required under subparagraphs 
     (B) and (C) of paragraph (2). The Director may fund a project 
     of such eligible entity in an amount not to exceed 
     $15,000,000 for a fiscal year subsequent to the initial award 
     under clause (i).
       ``(iii) Matching funds.--As a condition for receiving an 
     award under this subsection, an eligible entity shall 
     contribute to the project non-Federal funds in the amount of 
     $1 for every $3 awarded under clauses (i) and (ii), except 
     that the Director of NIH may waive or modify such matching 
     requirement in any case where the Director determines that 
     the goals and objectives of this section cannot adequately be 
     carried out unless such requirement is waived.

[[Page 32780]]

       ``(B) The cures acceleration grant awards.--
       ``(i) Initial award amount.--Each award under this 
     subparagraph shall be not more than $15,000,000 per project 
     for the first fiscal year for which the project is funded, 
     which shall be payable in one payment.
       ``(ii) Funding in subsequent fiscal years.--An eligible 
     entity receiving an award under clause (i) may apply for 
     additional funding for such project by submitting to the 
     Board the information required under subparagraphs (B) and 
     (C) of paragraph (2). The Director of NIH may fund a project 
     of such eligible entity in an amount not to exceed 
     $15,000,000 for a fiscal year subsequent to the initial award 
     under clause (i).
       ``(C) The cures acceleration flexible research awards.--If 
     the Director of NIH determines that the goals and objectives 
     of this section cannot adequately be carried out through a 
     contract, grant, or cooperative agreement, the Director of 
     NIH shall have flexible research authority to use other 
     transactions to fund projects in accordance with the terms 
     and conditions of this section. Awards made under such 
     flexible research authority for a fiscal year shall not 
     exceed 20 percent of the total funds appropriated under 
     subsection (g)(1) for such fiscal year.
       ``(4) Suspension of awards for defaults, noncompliance with 
     provisions and plans, and diversion of funds; repayment of 
     funds.--The Director of NIH may suspend the award to any 
     entity upon noncompliance by such entity with provisions and 
     plans under this section or diversion of funds.
       ``(5) Audits.--The Director of NIH may enter into 
     agreements with other entities to conduct periodic audits of 
     the projects funded by grants or contracts awarded under this 
     subsection.
       ``(6) Closeout procedures.--At the end of a grant or 
     contract period, a recipient shall follow the closeout 
     procedures under section 74.71 of title 45, Code of Federal 
     Regulations (or any successor regulation).
       ``(7) Review.--A determination by the Director of NIH as to 
     whether a drug, device, or biological product is a high need 
     cure (for purposes of subsection (a)(3)) shall not be subject 
     to judicial review.
       ``(f) Competitive Basis of Awards.--Any grant, cooperative 
     agreement, or contract awarded under this section shall be 
     awarded on a competitive basis.
       ``(g) Authorization of Appropriations.--
       ``(1) In general.--For purposes of carrying out this 
     section, there are authorized to be appropriated $500,000,000 
     for fiscal year 2010, and such sums as may be necessary for 
     subsequent fiscal years. Funds appropriated under this 
     section shall be available until expended.
       ``(2) Limitation on use of funds otherwise appropriated.--
     No funds appropriated under this Act, other than funds 
     appropriated under paragraph (1), may be allocated to the 
     Cures Acceleration Network.''.

     SEC. 10410. CENTERS OF EXCELLENCE FOR DEPRESSION.

       (a) Short Title.--This section may be cited as the 
     ``Establishing a Network of Health-Advancing National Centers 
     of Excellence for Depression Act of 2009'' or the ``ENHANCED 
     Act of 2009''.
       (b) Centers of Excellence for Depression.--Subpart 3 of 
     part B of title V of the Public Health Service Act (42 U.S.C. 
     290bb et seq.) is amended by inserting after section 520A the 
     following:

     ``SEC. 520B. NATIONAL CENTERS OF EXCELLENCE FOR DEPRESSION.

       ``(a) Depressive Disorder Defined.--In this section, the 
     term `depressive disorder' means a mental or brain disorder 
     relating to depression, including major depression, bipolar 
     disorder, and related mood disorders.
       ``(b) Grant Program.--
       ``(1) In general.--The Secretary, acting through the 
     Administrator, shall award grants on a competitive basis to 
     eligible entities to establish national centers of excellence 
     for depression (referred to in this section as `Centers'), 
     which shall engage in activities related to the treatment of 
     depressive disorders.
       ``(2) Allocation of awards.--If the funds authorized under 
     subsection (f) are appropriated in the amounts provided for 
     under such subsection, the Secretary shall allocate such 
     amounts so that--
       ``(A) not later than 1 year after the date of enactment of 
     the ENHANCED Act of 2009, not more than 20 Centers may be 
     established; and
       ``(B) not later than September 30, 2016, not more than 30 
     Centers may be established.
       ``(3) Grant period.--
       ``(A) In general.--A grant awarded under this section shall 
     be for a period of 5 years.
       ``(B) Renewal.--A grant awarded under subparagraph (A) may 
     be renewed, on a competitive basis, for 1 additional 5-year 
     period, at the discretion of the Secretary. In determining 
     whether to renew a grant, the Secretary shall consider the 
     report cards issued under subsection (e)(2).
       ``(4) Use of funds.--Grant funds awarded under this 
     subsection shall be used for the establishment and ongoing 
     activities of the recipient of such funds.
       ``(5) Eligible entities.--
       ``(A) Requirements.--To be eligible to receive a grant 
     under this section, an entity shall--
       ``(i) be an institution of higher education or a public or 
     private nonprofit research institution; and
       ``(ii) submit an application to the Secretary at such time 
     and in such manner as the Secretary may require, as described 
     in subparagraph (B).
       ``(B) Application.--An application described in 
     subparagraph (A)(ii) shall include--
       ``(i) evidence that such entity--

       ``(I) provides, or is capable of coordinating with other 
     entities to provide, comprehensive health services with a 
     focus on mental health services and subspecialty expertise 
     for depressive disorders;
       ``(II) collaborates with other mental health providers, as 
     necessary, to address co-occurring mental illnesses;
       ``(III) is capable of training health professionals about 
     mental health; and

       ``(ii) such other information, as the Secretary may 
     require.
       ``(C) Priorities.--In awarding grants under this section, 
     the Secretary shall give priority to eligible entities that 
     meet 1 or more of the following criteria:
       ``(i) Demonstrated capacity and expertise to serve the 
     targeted population.
       ``(ii) Existing infrastructure or expertise to provide 
     appropriate, evidence-based and culturally and linguistically 
     competent services.
       ``(iii) A location in a geographic area with 
     disproportionate numbers of underserved and at-risk 
     populations in medically underserved areas and health 
     professional shortage areas.
       ``(iv) Proposed innovative approaches for outreach to 
     initiate or expand services.
       ``(v) Use of the most up-to-date science, practices, and 
     interventions available.
       ``(vi) Demonstrated capacity to establish cooperative and 
     collaborative agreements with community mental health centers 
     and other community entities to provide mental health, 
     social, and human services to individuals with depressive 
     disorders.
       ``(6) National coordinating center.--
       ``(A) In general.--The Secretary, acting through the 
     Administrator, shall designate 1 recipient of a grant under 
     this section to be the coordinating center of excellence for 
     depression (referred to in this section as the `coordinating 
     center'). The Secretary shall select such coordinating center 
     on a competitive basis, based upon the demonstrated capacity 
     of such center to perform the duties described in 
     subparagraph (C).
       ``(B) Application.--A Center that has been awarded a grant 
     under paragraph (1) may apply for designation as the 
     coordinating center by submitting an application to the 
     Secretary at such time, in such manner, and containing such 
     information as the Secretary may require.
       ``(C) Duties.--The coordinating center shall--
       ``(i) develop, administer, and coordinate the network of 
     Centers under this section;
       ``(ii) oversee and coordinate the national database 
     described in subsection (d);
       ``(iii) lead a strategy to disseminate the findings and 
     activities of the Centers through such database; and
       ``(iv) serve as a liaison with the Administration, the 
     National Registry of Evidence-based Programs and Practices of 
     the Administration, and any Federal interagency or 
     interagency forum on mental health.
       ``(7) Matching funds.--The Secretary may not award a grant 
     or contract under this section to an entity unless the entity 
     agrees that it will make available (directly or through 
     contributions from other public or private entities) non-
     Federal contributions toward the activities to be carried out 
     under the grant or contract in an amount equal to $1 for each 
     $5 of Federal funds provided under the grant or contract. 
     Such non-Federal matching funds may be provided directly or 
     through donations from public or private entities and may be 
     in cash or in-kind, fairly evaluated, including plant, 
     equipment, or services.
       ``(c) Activities of the Centers.--Each Center shall carry 
     out the following activities:
       ``(1) General activities.--Each Center shall--
       ``(A) integrate basic, clinical, or health services 
     interdisciplinary research and practice in the development, 
     implementation, and dissemination of evidence-based 
     interventions;
       ``(B) involve a broad cross-section of stakeholders, such 
     as researchers, clinicians, consumers, families of consumers, 
     and voluntary health organizations, to develop a research 
     agenda and disseminate findings, and to provide support in 
     the implementation of evidence-based practices;
       ``(C) provide training and technical assistance to mental 
     health professionals, and engage in and disseminate 
     translational research with a focus on meeting the needs of 
     individuals with depressive disorders; and
       ``(D) educate policy makers, employers, community leaders, 
     and the public about depressive disorders to reduce stigma 
     and raise awareness of treatments.
       ``(2) Improved treatment standards, clinical guidelines, 
     diagnostic protocols, and care coordination practice.--Each

[[Page 32781]]

     Center shall collaborate with other Centers in the network 
     to--
       ``(A) develop and implement treatment standards, clinical 
     guidelines, and protocols that emphasize primary prevention, 
     early intervention, treatment for, and recovery from, 
     depressive disorders;
       ``(B) foster communication with other providers attending 
     to co-occurring physical health conditions such as 
     cardiovascular, diabetes, cancer, and substance abuse 
     disorders;
       ``(C) leverage available community resources, develop and 
     implement improved self-management programs, and, when 
     appropriate, involve family and other providers of social 
     support in the development and implementation of care plans; 
     and
       ``(D) use electronic health records and telehealth 
     technology to better coordinate and manage, and improve 
     access to, care, as determined by the coordinating center.
       ``(3) Translational research through collaboration of 
     centers and community-based organizations.--Each Center 
     shall--
       ``(A) demonstrate effective use of a public-private 
     partnership to foster collaborations among members of the 
     network and community-based organizations such as community 
     mental health centers and other social and human services 
     providers;
       ``(B) expand interdisciplinary, translational, and patient-
     oriented research and treatment; and
       ``(C) coordinate with accredited academic programs to 
     provide ongoing opportunities for the professional and 
     continuing education of mental health providers.
       ``(d) National Database.--
       ``(1) In general.--The coordinating center shall establish 
     and maintain a national, publicly available database to 
     improve prevention programs, evidence-based interventions, 
     and disease management programs for depressive disorders, 
     using data collected from the Centers, as described in 
     paragraph (2).
       ``(2) Data collection.--Each Center shall submit data 
     gathered at such center, as appropriate, to the coordinating 
     center regarding--
       ``(A) the prevalence and incidence of depressive disorders;
       ``(B) the health and social outcomes of individuals with 
     depressive disorders;
       ``(C) the effectiveness of interventions designed, tested, 
     and evaluated;
       ``(D) other information, as the Secretary may require.
       ``(3) Submission of data to the administrator.--The 
     coordinating center shall submit to the Administrator the 
     data and financial information gathered under paragraph (2).
       ``(4) Publication using data from the database.--A Center, 
     or an individual affiliated with a Center, may publish 
     findings using the data described in paragraph (2) only if 
     such center submits such data to the coordinating center, as 
     required under such paragraph.
       ``(e) Establishment of Standards; Report Cards and 
     Recommendations; Third Party Review.--
       ``(1) Establishment of standards.--The Secretary, acting 
     through the Administrator, shall establish performance 
     standards for--
       ``(A) each Center; and
       ``(B) the network of Centers as a whole.
       ``(2) Report cards.--The Secretary, acting through the 
     Administrator, shall--
       ``(A) for each Center, not later than 3 years after the 
     date on which such center of excellence is established and 
     annually thereafter, issue a report card to the coordinating 
     center to rate the performance of such Center; and
       ``(B) not later than 3 years after the date on which the 
     first grant is awarded under subsection (b)(1) and annually 
     thereafter, issue a report card to Congress to rate the 
     performance of the network of centers of excellence as a 
     whole.
       ``(3) Recommendations.--Based upon the report cards 
     described in paragraph (2), the Secretary shall, not later 
     than September 30, 2015--
       ``(A) make recommendations to the Centers regarding 
     improvements such centers shall make; and
       ``(B) make recommendations to Congress for expanding the 
     Centers to serve individuals with other types of mental 
     disorders.
       ``(4) Third party review.--Not later than 3 years after the 
     date on which the first grant is awarded under subsection 
     (b)(1) and annually thereafter, the Secretary shall arrange 
     for an independent third party to conduct an evaluation of 
     the network of Centers to ensure that such centers are 
     meeting the goals of this section.
       ``(f) Authorization of Appropriations.--
       ``(1) In general.--To carry out this section, there are 
     authorized to be appropriated--
       ``(A) $100,000,000 for each of the fiscal years 2011 
     through 2015; and
       ``(B) $150,000,000 for each of the fiscal years 2016 
     through 2020.
       ``(2) Allocation of funds authorized.--Of the amount 
     appropriated under paragraph (1) for a fiscal year, the 
     Secretary shall determine the allocation of each Center 
     receiving a grant under this section, but in no case may the 
     allocation be more than $5,000,000, except that the Secretary 
     may allocate not more than $10,000,000 to the coordinating 
     center.''.

     SEC. 10411. PROGRAMS RELATING TO CONGENITAL HEART DISEASE.

       (a) Short Title.--This subtitle may be cited as the 
     ``Congenital Heart Futures Act''.
       (b) Programs Relating to Congenital Heart Disease.--
       (1) National congenital heart disease surveillance 
     system.--Part P of title III of the Public Health Service Act 
     (42 U.S.C. 280g et seq.), as amended by section 5405, is 
     further amended by adding at the end the following:

     ``SEC. 399V-2. NATIONAL CONGENITAL HEART DISEASE SURVEILLANCE 
                   SYSTEM.

       ``(a) In General.--The Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     may--
       ``(1) enhance and expand infrastructure to track the 
     epidemiology of congenital heart disease and to organize such 
     information into a nationally-representative, population-
     based surveillance system that compiles data concerning 
     actual occurrences of congenital heart disease, to be known 
     as the `National Congenital Heart Disease Surveillance 
     System'; or
       ``(2) award a grant to one eligible entity to undertake the 
     activities described in paragraph (1).
       ``(b) Purpose.--The purpose of the Congenital Heart Disease 
     Surveillance System shall be to facilitate further research 
     into the types of health services patients use and to 
     identify possible areas for educational outreach and 
     prevention in accordance with standard practices of the 
     Centers for Disease Control and Prevention.
       ``(c) Content.--The Congenital Heart Disease Surveillance 
     System--
       ``(1) may include information concerning the incidence and 
     prevalence of congenital heart disease in the United States;
       ``(2) may be used to collect and store data on congenital 
     heart disease, including data concerning--
       ``(A) demographic factors associated with congenital heart 
     disease, such as age, race, ethnicity, sex, and family 
     history of individuals who are diagnosed with the disease;
       ``(B) risk factors associated with the disease;
       ``(C) causation of the disease;
       ``(D) treatment approaches; and
       ``(E) outcome measures, such that analysis of the outcome 
     measures will allow derivation of evidence-based best 
     practices and guidelines for congenital heart disease 
     patients; and
       ``(3) may ensure the collection and analysis of 
     longitudinal data related to individuals of all ages with 
     congenital heart disease, including infants, young children, 
     adolescents, and adults of all ages.
       ``(d) Public Access.--The Congenital Heart Disease 
     Surveillance System shall be made available to the public, as 
     appropriate, including congenital heart disease researchers.
       ``(e) Patient Privacy.--The Secretary shall ensure that the 
     Congenital Heart Disease Surveillance System is maintained in 
     a manner that complies with the regulations promulgated under 
     section 264 of the Health Insurance Portability and 
     Accountability Act of 1996.
       ``(f) Eligibility for Grant.--To be eligible to receive a 
     grant under subsection (a)(2), an entity shall--
       ``(1) be a public or private nonprofit entity with 
     specialized experience in congenital heart disease; and
       ``(2) submit to the Secretary an application at such time, 
     in such manner, and containing such information as the 
     Secretary may require.''.
       (2) Congenital heart disease research.--Subpart 2 of part C 
     of title IV of the Public Health Service Act (42 U.S.C. 285b 
     et seq.) is amended by adding at the end the following:

     ``SEC. 425. CONGENITAL HEART DISEASE.

       ``(a) In General.--The Director of the Institute may 
     expand, intensify, and coordinate research and related 
     activities of the Institute with respect to congenital heart 
     disease, which may include congenital heart disease research 
     with respect to--
       ``(1) causation of congenital heart disease, including 
     genetic causes;
       ``(2) long-term outcomes in individuals with congenital 
     heart disease, including infants, children, teenagers, 
     adults, and elderly individuals;
       ``(3) diagnosis, treatment, and prevention;
       ``(4) studies using longitudinal data and retrospective 
     analysis to identify effective treatments and outcomes for 
     individuals with congenital heart disease; and
       ``(5) identifying barriers to life-long care for 
     individuals with congenital heart disease.
       ``(b) Coordination of Research Activities.--The Director of 
     the Institute may coordinate research efforts related to 
     congenital heart disease among multiple research institutions 
     and may develop research networks.
       ``(c) Minority and Medically Underserved Communities.--In 
     carrying out the activities described in this section, the 
     Director of the Institute shall consider the application of 
     such research and other activities to minority and medically 
     underserved communities.''.
       (c) Authorization of Appropriations.--There are authorized 
     to be appropriated to

[[Page 32782]]

     carry out the amendments made by this section such sums as 
     may be necessary for each of fiscal years 2011 through 2015.

     SEC. 10412. AUTOMATED DEFIBRILLATION IN ADAM'S MEMORY ACT.

       Section 312 of the Public Health Service Act (42 U.S.C. 
     244) is amended--
       (1) in subsection (c)(6), after ``clearinghouse'' insert 
     ``, that shall be administered by an organization that has 
     substantial expertise in pediatric education, pediatric 
     medicine, and electrophysiology and sudden death,''; and
       (2) in the first sentence of subsection (e), by striking 
     ``fiscal year 2003'' and all that follows through ``2006'' 
     and inserting ``for each of fiscal years 2003 through 2014''.

     SEC. 10413. YOUNG WOMEN'S BREAST HEALTH AWARENESS AND SUPPORT 
                   OF YOUNG WOMEN DIAGNOSED WITH BREAST CANCER.

       (a) Short Title.--This section may be cited as the ``Young 
     Women's Breast Health Education and Awareness Requires 
     Learning Young Act of 2009'' or the ``EARLY Act''.
       (b) Amendment.--Title III of the Public Health Service Act 
     (42 U.S.C. 241 et seq.), as amended by this Act, is further 
     amended by adding at the end the following:

        ``PART V--PROGRAMS RELATING TO BREAST HEALTH AND CANCER

     ``SEC. 399NN. YOUNG WOMEN'S BREAST HEALTH AWARENESS AND 
                   SUPPORT OF YOUNG WOMEN DIAGNOSED WITH BREAST 
                   CANCER.

       ``(a) Public Education Campaign.--
       ``(1) In general.--The Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     shall conduct a national evidence-based education campaign to 
     increase awareness of young women's knowledge regarding--
       ``(A) breast health in young women of all racial, ethnic, 
     and cultural backgrounds;
       ``(B) breast awareness and good breast health habits;
       ``(C) the occurrence of breast cancer and the general and 
     specific risk factors in women who may be at high risk for 
     breast cancer based on familial, racial, ethnic, and cultural 
     backgrounds such as Ashkenazi Jewish populations;
       ``(D) evidence-based information that would encourage young 
     women and their health care professional to increase early 
     detection of breast cancers; and
       ``(E) the availability of health information and other 
     resources for young women diagnosed with breast cancer.
       ``(2) Evidence-based, age appropriate messages.--The 
     campaign shall provide evidence-based, age-appropriate 
     messages and materials as developed by the Centers for 
     Disease Control and Prevention and the Advisory Committee 
     established under paragraph (4).
       ``(3) Media campaign.--In conducting the education campaign 
     under paragraph (1), the Secretary shall award grants to 
     entities to establish national multimedia campaigns oriented 
     to young women that may include advertising through 
     television, radio, print media, billboards, posters, all 
     forms of existing and especially emerging social networking 
     media, other Internet media, and any other medium determined 
     appropriate by the Secretary.
       ``(4) Advisory committee.--
       ``(A) Establishment.--Not later than 60 days after the date 
     of the enactment of this section, the Secretary, acting 
     through the Director of the Centers for Disease Control and 
     Prevention, shall establish an advisory committee to assist 
     in creating and conducting the education campaigns under 
     paragraph (1) and subsection (b)(1).
       ``(B) Membership.--The Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     shall appoint to the advisory committee under subparagraph 
     (A) such members as deemed necessary to properly advise the 
     Secretary, and shall include organizations and individuals 
     with expertise in breast cancer, disease prevention, early 
     detection, diagnosis, public health, social marketing, 
     genetic screening and counseling, treatment, rehabilitation, 
     palliative care, and survivorship in young women.
       ``(b) Health Care Professional Education Campaign.--The 
     Secretary, acting through the Director of the Centers for 
     Disease Control and Prevention, and in consultation with the 
     Administrator of the Health Resources and Services 
     Administration, shall conduct an education campaign among 
     physicians and other health care professionals to increase 
     awareness--
       ``(1) of breast health, symptoms, and early diagnosis and 
     treatment of breast cancer in young women, including specific 
     risk factors such as family history of cancer and women that 
     may be at high risk for breast cancer, such as Ashkenazi 
     Jewish population;
       ``(2) on how to provide counseling to young women about 
     their breast health, including knowledge of their family 
     cancer history and importance of providing regular clinical 
     breast examinations;
       ``(3) concerning the importance of discussing healthy 
     behaviors, and increasing awareness of services and programs 
     available to address overall health and wellness, and making 
     patient referrals to address tobacco cessation, good 
     nutrition, and physical activity;
       ``(4) on when to refer patients to a health care provider 
     with genetics expertise;
       ``(5) on how to provide counseling that addresses long-term 
     survivorship and health concerns of young women diagnosed 
     with breast cancer; and
       ``(6) on when to provide referrals to organizations and 
     institutions that provide credible health information and 
     substantive assistance and support to young women diagnosed 
     with breast cancer.
       ``(c) Prevention Research Activities.--The Secretary, 
     acting through--
       ``(1) the Director of the Centers for Disease Control and 
     Prevention, shall conduct prevention research on breast 
     cancer in younger women, including--
       ``(A) behavioral, survivorship studies, and other research 
     on the impact of breast cancer diagnosis on young women;
       ``(B) formative research to assist with the development of 
     educational messages and information for the public, targeted 
     populations, and their families about breast health, breast 
     cancer, and healthy lifestyles;
       ``(C) testing and evaluating existing and new social 
     marketing strategies targeted at young women; and
       ``(D) surveys of health care providers and the public 
     regarding knowledge, attitudes, and practices related to 
     breast health and breast cancer prevention and control in 
     high-risk populations; and
       ``(2) the Director of the National Institutes of Health, 
     shall conduct research to develop and validate new screening 
     tests and methods for prevention and early detection of 
     breast cancer in young women.
       ``(d) Support for Young Women Diagnosed With Breast 
     Cancer.--
       ``(1) In general.--The Secretary shall award grants to 
     organizations and institutions to provide health information 
     from credible sources and substantive assistance directed to 
     young women diagnosed with breast cancer and pre-neoplastic 
     breast diseases.
       ``(2) Priority.--In making grants under paragraph (1), the 
     Secretary shall give priority to applicants that deal 
     specifically with young women diagnosed with breast cancer 
     and pre-neoplastic breast disease.
       ``(e) No Duplication of Effort.--In conducting an education 
     campaign or other program under subsections (a), (b), (c), or 
     (d), the Secretary shall avoid duplicating other existing 
     Federal breast cancer education efforts.
       ``(f) Measurement; Reporting.--The Secretary, acting 
     through the Director of the Centers for Disease Control and 
     Prevention, shall--
       ``(1) measure--
       ``(A) young women's awareness regarding breast health, 
     including knowledge of family cancer history, specific risk 
     factors and early warning signs, and young women's proactive 
     efforts at early detection;
       ``(B) the number or percentage of young women utilizing 
     information regarding lifestyle interventions that foster 
     healthy behaviors;
       ``(C) the number or percentage of young women receiving 
     regular clinical breast exams; and
       ``(D) the number or percentage of young women who perform 
     breast self exams, and the frequency of such exams, before 
     the implementation of this section;
       ``(2) not less than every 3 years, measure the impact of 
     such activities; and
       ``(3) submit reports to the Congress on the results of such 
     measurements.
       ``(g) Definition.--In this section, the term `young women' 
     means women 15 to 44 years of age.
       ``(h) Authorization of Appropriations.--To carry out 
     subsections (a), (b), (c)(1), and (d), there are authorized 
     to be appropriated $9,000,000 for each of the fiscal years 
     2010 through 2014.''.

               Subtitle E--Provisions Relating to Title V

     SEC. 10501. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT, THE 
                   SOCIAL SECURITY ACT, AND TITLE V OF THIS ACT.

       (a) Section 5101 of this Act is amended--
       (1) in subsection (c)(2)(B)(i)(II), by inserting ``, 
     including representatives of small business and self-employed 
     individuals'' after ``employers'';
       (2) in subsection (d)(4)(A)--
       (A) by redesignating clause (iv) as clause (v); and
       (B) by inserting after clause (iii) the following:
       ``(iv) An analysis of, and recommendations for, eliminating 
     the barriers to entering and staying in primary care, 
     including provider compensation.''; and
       (3) in subsection (i)(2)(B), by inserting ``optometrists, 
     ophthalmologists,'' after ``occupational therapists,''.
       (b) Subtitle B of title V of this Act is amended by adding 
     at the end the following:

     ``SEC. 5104. INTERAGENCY TASK FORCE TO ASSESS AND IMPROVE 
                   ACCESS TO HEALTH CARE IN THE STATE OF ALASKA.

       ``(a) Establishment.--There is established a task force to 
     be known as the `Interagency Access to Health Care in Alaska 
     Task Force' (referred to in this section as the `Task 
     Force').
       ``(b) Duties.--The Task Force shall--
       ``(1) assess access to health care for beneficiaries of 
     Federal health care systems in Alaska; and

[[Page 32783]]

       ``(2) develop a strategy for the Federal Government to 
     improve delivery of health care to Federal beneficiaries in 
     the State of Alaska.
       ``(c) Membership.--The Task Force shall be comprised of 
     Federal members who shall be appointed, not later than 45 
     days after the date of enactment of this Act, as follows:
       ``(1) The Secretary of Health and Human Services shall 
     appoint one representative of each of the following:
       ``(A) The Department of Health and Human Services.
       ``(B) The Centers for Medicare and Medicaid Services.
       ``(C) The Indian Health Service.
       ``(2) The Secretary of Defense shall appoint one 
     representative of the TRICARE Management Activity.
       ``(3) The Secretary of the Army shall appoint one 
     representative of the Army Medical Department.
       ``(4) The Secretary of the Air Force shall appoint one 
     representative of the Air Force, from among officers at the 
     Air Force performing medical service functions.
       ``(5) The Secretary of Veterans Affairs shall appoint one 
     representative of each of the following:
       ``(A) The Department of Veterans Affairs.
       ``(B) The Veterans Health Administration.
       ``(6) The Secretary of Homeland Security shall appoint one 
     representative of the United States Coast Guard.
       ``(d) Chairperson.--One chairperson of the Task Force shall 
     be appointed by the Secretary at the time of appointment of 
     members under subsection (c), selected from among the members 
     appointed under paragraph (1).
       ``(e) Meetings.--The Task Force shall meet at the call of 
     the chairperson.
       ``(f) Report.--Not later than 180 days after the date of 
     enactment of this Act, the Task Force shall submit to 
     Congress a report detailing the activities of the Task Force 
     and containing the findings, strategies, recommendations, 
     policies, and initiatives developed pursuant to the duty 
     described in subsection (b)(2). In preparing such report, the 
     Task Force shall consider completed and ongoing efforts by 
     Federal agencies to improve access to health care in the 
     State of Alaska.
       ``(g) Termination.--The Task Force shall be terminated on 
     the date of submission of the report described in subsection 
     (f).''.
       (c) Section 399V of the Public Health Service Act, as added 
     by section 5313, is amended--
       (1) in subsection (b)(4), by striking ``identify, educate, 
     refer, and enroll'' and inserting ``identify and refer''; and
       (2) in subsection (k)(1), by striking ``, as defined by the 
     Department of Labor as Standard Occupational Classification 
     [21-1094]''.
       (d) Section 738(a)(3) of the Public Health Service Act (42 
     U.S.C. 293b(a)(3)) is amended by inserting ``schools offering 
     physician assistant education programs,'' after ``public 
     health,''.
       (e) Subtitle D of title V of this Act is amended by adding 
     at the end the following:

     ``SEC. 5316. DEMONSTRATION GRANTS FOR FAMILY NURSE 
                   PRACTITIONER TRAINING PROGRAMS.

       ``(a) Establishment of Program.--The Secretary of Health 
     and Human Services (referred to in this section as the 
     `Secretary') shall establish a training demonstration program 
     for family nurse practitioners (referred to in this section 
     as the `program') to employ and provide 1-year training for 
     nurse practitioners who have graduated from a nurse 
     practitioner program for careers as primary care providers in 
     Federally qualified health centers (referred to in this 
     section as `FQHCs') and nurse-managed health clinics 
     (referred to in this section as `NMHCs').
       ``(b) Purpose.--The purpose of the program is to enable 
     each grant recipient to--
       ``(1) provide new nurse practitioners with clinical 
     training to enable them to serve as primary care providers in 
     FQHCs and NMHCs;
       ``(2) train new nurse practitioners to work under a model 
     of primary care that is consistent with the principles set 
     forth by the Institute of Medicine and the needs of 
     vulnerable populations; and
       ``(3) create a model of FQHC and NMHC training for nurse 
     practitioners that may be replicated nationwide.
       ``(c) Grants.--The Secretary shall award 3-year grants to 
     eligible entities that meet the requirements established by 
     the Secretary, for the purpose of operating the nurse 
     practitioner primary care programs described in subsection 
     (a) in such entities.
       ``(d) Eligible Entities.--To be eligible to receive a grant 
     under this section, an entity shall--
       ``(1)(A) be a FQHC as defined in section 1861(aa) of the 
     Social Security Act (42 U.S.C. 1395x(aa)); or
       ``(B) be a nurse-managed health clinic, as defined in 
     section 330A-1 of the Public Health Service Act (as added by 
     section 5208 of this Act); and
       ``(2) submit to the Secretary an application at such time, 
     in such manner, and containing such information as the 
     Secretary may require.
       ``(e) Priority in Awarding Grants.--In awarding grants 
     under this section, the Secretary shall give priority to 
     eligible entities that--
       ``(1) demonstrate sufficient infrastructure in size, scope, 
     and capacity to undertake the requisite training of a minimum 
     of 3 nurse practitioners per year, and to provide to each 
     awardee 12 full months of full-time, paid employment and 
     benefits consistent with the benefits offered to other full-
     time employees of such entity;
       ``(2) will assign not less than 1 staff nurse practitioner 
     or physician to each of 4 precepted clinics;
       ``(3) will provide to each awardee specialty rotations, 
     including specialty training in prenatal care and women's 
     health, adult and child psychiatry, orthopedics, geriatrics, 
     and at least 3 other high-volume, high-burden specialty 
     areas;
       ``(4) provide sessions on high-volume, high-risk health 
     problems and have a record of training health care 
     professionals in the care of children, older adults, and 
     underserved populations; and
       ``(5) collaborate with other safety net providers, schools, 
     colleges, and universities that provide health professions 
     training.
       ``(f) Eligibility of Nurse Practitioners.--
       ``(1) In general.--To be eligible for acceptance to a 
     program funded through a grant awarded under this section, an 
     individual shall--
       ``(A) be licensed or eligible for licensure in the State in 
     which the program is located as an advanced practice 
     registered nurse or advanced practice nurse and be eligible 
     or board-certified as a family nurse practitioner; and
       ``(B) demonstrate commitment to a career as a primary care 
     provider in a FQHC or in a NMHC.
       ``(2) Preference.--In selecting awardees under the program, 
     each grant recipient shall give preference to bilingual 
     candidates that meet the requirements described in paragraph 
     (1).
       ``(3) Deferral of certain service.--The starting date of 
     required service of individuals in the National Health 
     Service Corps Service program under title II of the Public 
     Health Service Act (42 U.S.C. 202 et seq.) who receive 
     training under this section shall be deferred until the date 
     that is 22 days after the date of completion of the program.
       ``(g) Grant Amount.--Each grant awarded under this section 
     shall be in an amount not to exceed $600,000 per year. A 
     grant recipient may carry over funds from 1 fiscal year to 
     another without obtaining approval from the Secretary.
       ``(h) Technical Assistance Grants.--The Secretary may award 
     technical assistance grants to 1 or more FQHCs or NMHCs that 
     have demonstrated expertise in establishing a nurse 
     practitioner residency training program. Such technical 
     assistance grants shall be for the purpose of providing 
     technical assistance to other recipients of grants under 
     subsection (c).
       ``(i) Authorization of Appropriations.--To carry out this 
     section, there is authorized to be appropriated such sums as 
     may be necessary for each of fiscal years 2011 through 
     2014.''.
       (f)(1) Section 399W of the Public Health Service Act, as 
     added by section 5405, is redesignated as section 399V-1.
       (2) Section 399V-1 of the Public Health Service Act, as so 
     redesignated, is amended in subsection (b)(2)(A) by striking 
     ``and the departments of 1 or more health professions schools 
     in the State that train providers in primary care'' and 
     inserting ``and the departments that train providers in 
     primary care in 1 or more health professions schools in the 
     State''.
       (3) Section 934 of the Public Health Service Act, as added 
     by section 3501, is amended by striking ``399W'' each place 
     such term appears and inserting ``399V-1''.
       (4) Section 935(b) of the Public Health Service Act, as 
     added by section 3503, is amended by striking ``399W'' and 
     inserting ``399V-1''.
       (g) Part P of title III of the Public Health Service Act 42 
     U.S.C. 280g et seq.), as amended by section 10411, is amended 
     by adding at the end the following:

     ``SEC. 399V-3. NATIONAL DIABETES PREVENTION PROGRAM.

       ``(a) In General.--The Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     shall establish a national diabetes prevention program 
     (referred to in this section as the `program') targeted at 
     adults at high risk for diabetes in order to eliminate the 
     preventable burden of diabetes.
       ``(b) Program Activities.--The program described in 
     subsection (a) shall include--
       ``(1) a grant program for community-based diabetes 
     prevention program model sites;
       ``(2) a program within the Centers for Disease Control and 
     Prevention to determine eligibility of entities to deliver 
     community-based diabetes prevention services;
       ``(3) a training and outreach program for lifestyle 
     intervention instructors; and
       ``(4) evaluation, monitoring and technical assistance, and 
     applied research carried out by the Centers for Disease 
     Control and Prevention.
       ``(c) Eligible Entities.--To be eligible for a grant under 
     subsection (b)(1), an entity shall be a State or local health 
     department, a tribal organization, a national network of 
     community-based non-profits focused on

[[Page 32784]]

     health and wellbeing, an academic institution, or other 
     entity, as the Secretary determines.
       ``(d) Authorization of Appropriations.--For the purpose of 
     carrying out this section, there are authorized to be 
     appropriated such sums as may be necessary for each of fiscal 
     years 2010 through 2014.''.
       (h) The provisions of, and amendment made by, section 
     5501(c) of this Act are repealed.
       (i)(1) The provisions of, and amendments made by, section 
     5502 of this Act are repealed.
       (2)(A) Section 1861(aa)(3)(A) of the Social Security Act 
     (42 U.S.C. 1395w(aa)(3)(A)) is amended to read as follows:
       ``(A) services of the type described in subparagraphs (A) 
     through (C) of paragraph (1) and preventive services (as 
     defined in section 1861(ddd)(3)); and''.
       (B) The amendment made by subparagraph (A) shall apply to 
     services furnished on or after January 1, 2011.
       (3)(A) Section 1834 of the Social Security Act (42 U.S.C. 
     1395m), as amended by section 4105, is amended by adding at 
     the end the following new subsection:
       ``(o) Development and Implementation of Prospective Payment 
     System.--
       ``(1) Development.--
       ``(A) In general.--The Secretary shall develop a 
     prospective payment system for payment for Federally 
     qualified health center services furnished by Federally 
     qualified health centers under this title. Such system shall 
     include a process for appropriately describing the services 
     furnished by Federally qualified health centers and shall 
     establish payment rates for specific payment codes based on 
     such appropriate descriptions of services. Such system shall 
     be established to take into account the type, intensity, and 
     duration of services furnished by Federally qualified health 
     centers. Such system may include adjustments, including 
     geographic adjustments, determined appropriate by the 
     Secretary.
       ``(B) Collection of data and evaluation.--By not later than 
     January 1, 2011, the Secretary shall require Federally 
     qualified health centers to submit to the Secretary such 
     information as the Secretary may require in order to develop 
     and implement the prospective payment system under this 
     subsection, including the reporting of services using HCPCS 
     codes.
       ``(2) Implementation.--
       ``(A) In general.--Notwithstanding section 1833(a)(3)(A), 
     the Secretary shall provide, for cost reporting periods 
     beginning on or after October 1, 2014, for payments of 
     prospective payment rates for Federally qualified health 
     center services furnished by Federally qualified health 
     centers under this title in accordance with the prospective 
     payment system developed by the Secretary under paragraph 
     (1).
       ``(B) Payments.--
       ``(i) Initial payments.--The Secretary shall implement such 
     prospective payment system so that the estimated aggregate 
     amount of prospective payment rates (determined prior to the 
     application of section 1833(a)(1)(Z)) under this title for 
     Federally qualified health center services in the first year 
     that such system is implemented is equal to 100 percent of 
     the estimated amount of reasonable costs (determined without 
     the application of a per visit payment limit or productivity 
     screen and prior to the application of section 
     1866(a)(2)(A)(ii)) that would have occurred for such services 
     under this title in such year if the system had not been 
     implemented.
       ``(ii) Payments in subsequent years.--Payment rates in 
     years after the year of implementation of such system shall 
     be the payment rates in the previous year increased--

       ``(I) in the first year after implementation of such 
     system, by the percentage increase in the MEI (as defined in 
     section 1842(i)(3)) for the year involved; and
       ``(II) in subsequent years, by the percentage increase in a 
     market basket of Federally qualified health center goods and 
     services as promulgated through regulations, or if such an 
     index is not available, by the percentage increase in the MEI 
     (as defined in section 1842(i)(3)) for the year involved.

       ``(C) Preparation for pps implementation.--Notwithstanding 
     any other provision of law, the Secretary may establish and 
     implement by program instruction or otherwise the payment 
     codes to be used under the prospective payment system under 
     this section.''.
       (B) Section 1833(a)(1) of the Social Security Act (42 
     U.S.C. 1395l(a)(1)), as amended by section 4104, is amended--
       (i) by striking ``and'' before ``(Y)''; and
       (ii) by inserting before the semicolon at the end the 
     following: ``, and (Z) with respect to Federally qualified 
     health center services for which payment is made under 
     section 1834(o), the amounts paid shall be 80 percent of the 
     lesser of the actual charge or the amount determined under 
     such section''.
       (C) Section 1833(a) of the Social Security Act (42 U.S.C. 
     1395l(a)) is amended--
       (i) in paragraph (3)(B)(i)--
       (I) by inserting ``(I)'' after ``otherwise been provided''; 
     and
       (II) by inserting ``, or (II) in the case of such services 
     furnished on or after the implementation date of the 
     prospective payment system under section 1834(o), under such 
     section (calculated as if `100 percent' were substituted for 
     `80 percent' in such section) for such services if the 
     individual had not been so enrolled'' after ``been so 
     enrolled''; and
       (ii) by adding at the end the following flush sentence:

     ``Paragraph (3)(A) shall not apply to Federally qualified 
     health center services furnished on or after the 
     implementation date of the prospective payment system under 
     section 1834(0).''.
       (j) Section 5505 is amended by adding at the end the 
     following new subsection:
       ``(d) Application.--The amendments made by this section 
     shall not be applied in a manner that requires reopening of 
     any settled cost reports as to which there is not a 
     jurisdictionally proper appeal pending as of the date of the 
     enactment of this Act on the issue of payment for indirect 
     costs of medical education under section 1886(d)(5)(B) of the 
     Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct 
     graduate medical education costs under section 1886(h) of 
     such Act (42 U.S.C. 1395ww(h)).''.
       (k) Subtitle G of title V of this Act is amended by adding 
     at the end the following:

     ``SEC. 5606. STATE GRANTS TO HEALTH CARE PROVIDERS WHO 
                   PROVIDE SERVICES TO A HIGH PERCENTAGE OF 
                   MEDICALLY UNDERSERVED POPULATIONS OR OTHER 
                   SPECIAL POPULATIONS.

       ``(a) In General.--A State may award grants to health care 
     providers who treat a high percentage, as determined by such 
     State, of medically underserved populations or other special 
     populations in such State.
       ``(b) Source of Funds.--A grant program established by a 
     State under subsection (a) may not be established within a 
     department, agency, or other entity of such State that 
     administers the Medicaid program under title XIX of the 
     Social Security Act (42 U.S.C. 1396 et seq.), and no Federal 
     or State funds allocated to such Medicaid program, the 
     Medicare program under title XVIII of the Social Security Act 
     (42 U.S.C. 1395 et seq.), or the TRICARE program under 
     chapter 55 of title 10, United States Code, may be used to 
     award grants or to pay administrative costs associated with a 
     grant program established under subsection (a).''.
       (l) Part C of title VII of the Public Health Service Act 
     (42 U.S.C. 293k et seq.) is amended--
       (1) after the part heading, by inserting the following:

               ``Subpart I--Medical Training Generally'';

     and
       (2) by inserting at the end the following:

           ``Subpart II--Training in Underserved Communities

     ``SEC. 749B. RURAL PHYSICIAN TRAINING GRANTS.

       ``(a) In General.--The Secretary, acting through the 
     Administrator of the Health Resources and Services 
     Administration, shall establish a grant program for the 
     purposes of assisting eligible entities in recruiting 
     students most likely to practice medicine in underserved 
     rural communities, providing rural-focused training and 
     experience, and increasing the number of recent allopathic 
     and osteopathic medical school graduates who practice in 
     underserved rural communities.
       ``(b) Eligible Entities.--In order to be eligible to 
     receive a grant under this section, an entity shall--
       ``(1) be a school of allopathic or osteopathic medicine 
     accredited by a nationally recognized accrediting agency or 
     association approved by the Secretary for this purpose, or 
     any combination or consortium of such schools; and
       ``(2) submit an application to the Secretary that includes 
     a certification that such entity will use amounts provided to 
     the institution as described in subsection (d)(1).
       ``(c) Priority.--In awarding grant funds under this 
     section, the Secretary shall give priority to eligible 
     entities that--
       ``(1) demonstrate a record of successfully training 
     students, as determined by the Secretary, who practice 
     medicine in underserved rural communities;
       ``(2) demonstrate that an existing academic program of the 
     eligible entity produces a high percentage, as determined by 
     the Secretary, of graduates from such program who practice 
     medicine in underserved rural communities;
       ``(3) demonstrate rural community institutional 
     partnerships, through such mechanisms as matching or 
     contributory funding, documented in-kind services for 
     implementation, or existence of training partners with 
     interprofessional expertise in community health center 
     training locations or other similar facilities; or
       ``(4) submit, as part of the application of the entity 
     under subsection (b), a plan for the long-term tracking of 
     where the graduates of such entity practice medicine.
       ``(d) Use of Funds.--
       ``(1) Establishment.--An eligible entity receiving a grant 
     under this section shall use the funds made available under 
     such grant to establish, improve, or expand a rural-focused 
     training program (referred to in this section as the 
     `Program') meeting the requirements described in this 
     subsection and to carry out such program.
       ``(2) Structure of program.--An eligible entity shall--

[[Page 32785]]

       ``(A) enroll no fewer than 10 students per class year into 
     the Program; and
       ``(B) develop criteria for admission to the Program that 
     gives priority to students--
       ``(i) who have originated from or lived for a period of 2 
     or more years in an underserved rural community; and
       ``(ii) who express a commitment to practice medicine in an 
     underserved rural community.
       ``(3) Curricula.--The Program shall require students to 
     enroll in didactic coursework and clinical experience 
     particularly applicable to medical practice in underserved 
     rural communities, including--
       ``(A) clinical rotations in underserved rural communities, 
     and in applicable specialties, or other coursework or 
     clinical experience deemed appropriate by the Secretary; and
       ``(B) in addition to core school curricula, additional 
     coursework or training experiences focused on medical issues 
     prevalent in underserved rural communities.
       ``(4) Residency placement assistance.--Where available, the 
     Program shall assist all students of the Program in obtaining 
     clinical training experiences in locations with postgraduate 
     programs offering residency training opportunities in 
     underserved rural communities, or in local residency training 
     programs that support and train physicians to practice in 
     underserved rural communities.
       ``(5) Program student cohort support.--The Program shall 
     provide and require all students of the Program to 
     participate in group activities designed to further develop, 
     maintain, and reinforce the original commitment of such 
     students to practice in an underserved rural community.
       ``(e) Annual Reporting.--An eligible entity receiving a 
     grant under this section shall submit an annual report to the 
     Secretary on the success of the Program, based on criteria 
     the Secretary determines appropriate, including the residency 
     program selection of graduating students who participated in 
     the Program.
       ``(f) Regulations.--Not later than 60 days after the date 
     of enactment of this section, the Secretary shall by 
     regulation define `underserved rural community' for purposes 
     of this section.
       ``(g) Supplement Not Supplant.--Any eligible entity 
     receiving funds under this section shall use such funds to 
     supplement, not supplant, any other Federal, State, and local 
     funds that would otherwise be expended by such entity to 
     carry out the activities described in this section.
       ``(h) Maintenance of Effort.--With respect to activities 
     for which funds awarded under this section are to be 
     expended, the entity shall agree to maintain expenditures of 
     non-Federal amounts for such activities at a level that is 
     not less than the level of such expenditures maintained by 
     the entity for the fiscal year preceding the fiscal year for 
     which the entity receives a grant under this section.
       ``(i) Authorization of Appropriations.--There are 
     authorized to be appropriated $4,000,000 for each of the 
     fiscal years 2010 through 2013.''.
       (m)(1) Section 768 of the Public Health Service Act (42 
     U.S.C. 295c) is amended to read as follows:

     ``SEC. 768. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING 
                   GRANT PROGRAM.

       ``(a) Grants.--The Secretary, acting through the 
     Administrator of the Health Resources and Services 
     Administration and in consultation with the Director of the 
     Centers for Disease Control and Prevention, shall award 
     grants to, or enter into contracts with, eligible entities to 
     provide training to graduate medical residents in preventive 
     medicine specialties.
       ``(b) Eligibility.--To be eligible for a grant or contract 
     under subsection (a), an entity shall be--
       ``(1) an accredited school of public health or school of 
     medicine or osteopathic medicine;
       ``(2) an accredited public or private nonprofit hospital;
       ``(3) a State, local, or tribal health department; or
       ``(4) a consortium of 2 or more entities described in 
     paragraphs (1) through (3).
       ``(c) Use of Funds.--Amounts received under a grant or 
     contract under this section shall be used to--
       ``(1) plan, develop (including the development of 
     curricula), operate, or participate in an accredited 
     residency or internship program in preventive medicine or 
     public health;
       ``(2) defray the costs of practicum experiences, as 
     required in such a program; and
       ``(3) establish, maintain, or improve--
       ``(A) academic administrative units (including departments, 
     divisions, or other appropriate units) in preventive medicine 
     and public health; or
       ``(B) programs that improve clinical teaching in preventive 
     medicine and public health.
       ``(d) Report.--The Secretary shall submit to the Congress 
     an annual report on the program carried out under this 
     section.''.
       (2) Section 770(a) of the Public Health Service Act (42 
     U.S.C. 295e(a)) is amended to read as follows:
       ``(a) In General.--For the purpose of carrying out this 
     subpart, there is authorized to be appropriated $43,000,000 
     for fiscal year 2011, and such sums as may be necessary for 
     each of the fiscal years 2012 through 2015.''.
       (n)(1) Subsection (i) of section 331 of the Public Health 
     Service Act (42 U.S.C. 254d) of the Public Health Service Act 
     is amended--
       (A) in paragraph (1), by striking ``In carrying out subpart 
     III'' and all that follows through the period and inserting 
     ``In carrying out subpart III, the Secretary may, in 
     accordance with this subsection, issue waivers to individuals 
     who have entered into a contract for obligated service under 
     the Scholarship Program or the Loan Repayment Program under 
     which the individuals are authorized to satisfy the 
     requirement of obligated service through providing clinical 
     practice that is half time.'';
       (B) in paragraph (2)--
       (i) in subparagraphs (A)(ii) and (B), by striking ``less 
     than full time'' each place it appears and inserting ``half 
     time'';
       (ii) in subparagraphs (C) and (F), by striking ``less than 
     full-time service'' each place it appears and inserting 
     ``half-time service''; and
       (iii) by amending subparagraphs (D) and (E) to read as 
     follows:
       ``(D) the entity and the Corps member agree in writing that 
     the Corps member will perform half-time clinical practice;
       ``(E) the Corps member agrees in writing to fulfill all of 
     the service obligations under section 338C through half-time 
     clinical practice and either--
       ``(i) double the period of obligated service that would 
     otherwise be required; or
       ``(ii) in the case of contracts entered into under section 
     338B, accept a minimum service obligation of 2 years with an 
     award amount equal to 50 percent of the amount that would 
     otherwise be payable for full-time service; and''; and
       (C) in paragraph (3), by striking ``In evaluating a 
     demonstration project described in paragraph (1)'' and 
     inserting ``In evaluating waivers issued under paragraph 
     (1)''.
       (2) Subsection (j) of section 331 of the Public Health 
     Service Act (42 U.S.C. 254d) is amended by adding at the end 
     the following:
       ``(5) The terms `full time' and `full-time' mean a minimum 
     of 40 hours per week in a clinical practice, for a minimum of 
     45 weeks per year.
       ``(6) The terms `half time' and `half-time' mean a minimum 
     of 20 hours per week (not to exceed 39 hours per week) in a 
     clinical practice, for a minimum of 45 weeks per year.''.
       (3) Section 337(b)(1) of the Public Health Service Act (42 
     U.S.C. 254j(b)(1)) is amended by striking ``Members may not 
     be reappointed to the Council.''.
       (4) Section 338B(g)(2)(A) of the Public Health Service Act 
     (42 U.S.C. 254l-1(g)(2)(A)) is amended by striking 
     ``$35,000'' and inserting ``$50,000, plus, beginning with 
     fiscal year 2012, an amount determined by the Secretary on an 
     annual basis to reflect inflation,''.
       (5) Subsection (a) of section 338C of the Public Health 
     Service Act (42 U.S.C. 254m), as amended by section 5508, is 
     amended--
       (A) by striking the second sentence and inserting the 
     following: ``The Secretary may treat teaching as clinical 
     practice for up to 20 percent of such period of obligated 
     service.''; and
       (B) by adding at the end the following: ``Notwithstanding 
     the preceding sentence, with respect to a member of the Corps 
     participating in the teaching health centers graduate medical 
     education program under section 340H, for the purpose of 
     calculating time spent in full-time clinical practice under 
     this section, up to 50 percent of time spent teaching by such 
     member may be counted toward his or her service 
     obligation.''.

     SEC. 10502. INFRASTRUCTURE TO EXPAND ACCESS TO CARE.

       (a) Appropriation.--There are authorized to be 
     appropriated, and there are appropriated to the Department of 
     Health and Human Services, $100,000,000 for fiscal year 2010, 
     to remain available for obligation until September 30, 2011, 
     to be used for debt service on, or direct construction or 
     renovation of, a health care facility that provides research, 
     inpatient tertiary care, or outpatient clinical services. 
     Such facility shall be affiliated with an academic health 
     center at a public research university in the United States 
     that contains a State's sole public academic medical and 
     dental school.
       (b) Requirement.--Amount appropriated under subsection (a) 
     may only be made available by the Secretary of Health and 
     Human Services upon the receipt of an application from the 
     Governor of a State that certifies that--
       (1) the new health care facility is critical for the 
     provision of greater access to health care within the State;
       (2) such facility is essential for the continued financial 
     viability of the State's sole public medical and dental 
     school and its academic health center;
       (3) the request for Federal support represents not more 
     than 40 percent of the total cost of the proposed new 
     facility; and
       (4) the State has established a dedicated funding mechanism 
     to provide all remaining funds necessary to complete the 
     construction or renovation of the proposed facility.

     SEC. 10503. COMMUNITY HEALTH CENTERS AND THE NATIONAL HEALTH 
                   SERVICE CORPS FUND.

       (a) Purpose.--It is the purpose of this section to 
     establish a Community Health Center

[[Page 32786]]

     Fund (referred to in this section as the ``CHC Fund''), to be 
     administered through the Office of the Secretary of the 
     Department of Health and Human Services to provide for 
     expanded and sustained national investment in community 
     health centers under section 330 of the Public Health Service 
     Act and the National Health Service Corps.
       (b) Funding.--There is authorized to be appropriated, and 
     there is appropriated, out of any monies in the Treasury not 
     otherwise appropriated, to the CHC Fund--
       (1) to be transferred to the Secretary of Health and Human 
     Services to provide enhanced funding for the community health 
     center program under section 330 of the Public Health Service 
     Act--
       (A) $700,000,000 for fiscal year 2011;
       (B) $800,000,000 for fiscal year 2012;
       (C) $1,000,000,000 for fiscal year 2013;
       (D) $1,600,000,000 for fiscal year 2014; and
       (E) $2,900,000,000 for fiscal year 2015; and
       (2) to be transferred to the Secretary of Health and Human 
     Services to provide enhanced funding for the National Health 
     Service Corps--
       (A) $290,000,000 for fiscal year 2011;
       (B) $295,000,000 for fiscal year 2012;
       (C) $300,000,000 for fiscal year 2013;
       (D) $305,000,000 for fiscal year 2014; and
       (E) $310,000,000 for fiscal year 2015.
       (c) Construction.--There is authorized to be appropriated, 
     and there is appropriated, out of any monies in the Treasury 
     not otherwise appropriated, $1,500,000,000 to be available 
     for fiscal years 2011 through 2015 to be used by the 
     Secretary of Health and Human Services for the construction 
     and renovation of community health centers.
       (d) Use of Fund.--The Secretary of Health and Human 
     Services shall transfer amounts in the CHC Fund to accounts 
     within the Department of Health and Human Services to 
     increase funding, over the fiscal year 2008 level, for 
     community health centers and the National Health Service 
     Corps.
       (e) Availability.--Amounts appropriated under subsections 
     (b) and (c) shall remain available until expended.

     SEC. 10504. DEMONSTRATION PROJECT TO PROVIDE ACCESS TO 
                   AFFORDABLE CARE.

       (a) In General.--Not later than 6 months after the date of 
     enactment of this Act, the Secretary of Health and Human 
     Services (referred to in this section as the ``Secretary''), 
     acting through the Health Resources and Services 
     Administration, shall establish a 3 year demonstration 
     project in up to 10 States to provide access to comprehensive 
     health care services to the uninsured at reduced fees. The 
     Secretary shall evaluate the feasibility of expanding the 
     project to additional States.
       (b) Eligibility.--To be eligible to participate in the 
     demonstration project, an entity shall be a State-based, 
     nonprofit, public-private partnership that provides access to 
     comprehensive health care services to the uninsured at 
     reduced fees. Each State in which a participant selected by 
     the Secretary is located shall receive not more than 
     $2,000,000 to establish and carry out the project for the 3-
     year demonstration period.
       (c) Authorization.--There is authorized to be appropriated 
     such sums as may be necessary to carry out this section.

              Subtitle F--Provisions Relating to Title VI

     SEC. 10601. REVISIONS TO LIMITATION ON MEDICARE EXCEPTION TO 
                   THE PROHIBITION ON CERTAIN PHYSICIAN REFERRALS 
                   FOR HOSPITALS.

       (a) In General.--Section 1877(i) of the Social Security 
     Act, as added by section 6001(a), is amended--
       (1) in paragraph (1)(A)(i), by striking ``February 1, 
     2010'' and inserting ``August 1, 2010''; and
       (2) in paragraph (3)(A)--
       (A) in clause (iii), by striking ``August 1, 2011'' and 
     inserting ``February 1, 2012''; and
       (B) in clause (iv), by striking ``July 1, 2011'' and 
     inserting ``January 1, 2012''.
       (b) Conforming Amendment.--Section 6001(b)(2) of this Act 
     is amended by striking ``November 1, 2011'' and inserting 
     ``May 1, 2012''.

     SEC. 10602. CLARIFICATIONS TO PATIENT-CENTERED OUTCOMES 
                   RESEARCH.

       Section 1181 of the Social Security Act (as added by 
     section 6301) is amended--
       (1) in subsection (d)(2)(B)--
       (A) in clause (ii)(IV)--
       (i) by inserting ``, as described in subparagraph 
     (A)(ii),'' after ``original research''; and
       (ii) by inserting ``, as long as the researcher enters into 
     a data use agreement with the Institute for use of the data 
     from the original research, as appropriate'' after 
     ``publication''; and
       (B) by amending clause (iv) to read as follows:
       ``(iv) Subsequent use of the data.--The Institute shall not 
     allow the subsequent use of data from original research in 
     work-for-hire contracts with individuals, entities, or 
     instrumentalities that have a financial interest in the 
     results, unless approved under a data use agreement with the 
     Institute.'';
       (2) in subsection (d)(8)(A)(iv), by striking ``not be 
     construed as mandates for'' and inserting ``do not include''; 
     and
       (3) in subsection (f)(1)(C), by amending clause (ii) to 
     read as follows:
       ``(ii) 7 members representing physicians and providers, 
     including 4 members representing physicians (at least 1 of 
     whom is a surgeon), 1 nurse, 1 State-licensed integrative 
     health care practitioner, and 1 representative of a 
     hospital.''.

     SEC. 10603. STRIKING PROVISIONS RELATING TO INDIVIDUAL 
                   PROVIDER APPLICATION FEES.

       (a) In General.--Section 1866(j)(2)(C) of the Social 
     Security Act, as added by section 6401(a), is amended--
       (1) by striking clause (i);
       (2) by redesignating clauses (ii) through (iv), 
     respectively, as clauses (i) through (iii); and
       (3) in clause (i), as redesignated by paragraph (2), by 
     striking ``clause (iii)'' and inserting ``clause (ii)''.
       (b) Technical Correction.--Section 6401(a)(2) of this Act 
     is amended to read as follows:
       ``(2) by redesignating paragraph (2) as paragraph (8); 
     and''.

     SEC. 10604. TECHNICAL CORRECTION TO SECTION 6405.

       Paragraphs (1) and (2) of section 6405(b) are amended to 
     read as follows:
       ``(1) Part a.--Section 1814(a)(2) of the Social Security 
     Act (42 U.S.C. 1395(a)(2)) is amended in the matter preceding 
     subparagraph (A) by inserting `, or, in the case of services 
     described in subparagraph (C), a physician enrolled under 
     section 1866(j),' after `in collaboration with a physician,'.
       ``(2) Part b.--Section 1835(a)(2) of the Social Security 
     Act (42 U.S.C. 1395n(a)(2)) is amended in the matter 
     preceding subparagraph (A) by inserting `, or, in the case of 
     services described in subparagraph (A), a physician enrolled 
     under section 1866(j),' after `a physician'.''.

     SEC. 10605. CERTAIN OTHER PROVIDERS PERMITTED TO CONDUCT FACE 
                   TO FACE ENCOUNTER FOR HOME HEALTH SERVICES.

       (a) Part A.--Section 1814(a)(2)(C) of the Social Security 
     Act (42 U.S.C. 1395f(a)(2)(C)), as amended by section 
     6407(a)(1), is amended by inserting ``, or a nurse 
     practitioner or clinical nurse specialist (as those terms are 
     defined in section 1861(aa)(5)) who is working in 
     collaboration with the physician in accordance with State 
     law, or a certified nurse-midwife (as defined in section 
     1861(gg)) as authorized by State law, or a physician 
     assistant (as defined in section 1861(aa)(5)) under the 
     supervision of the physician,'' after ``himself or herself''.
       (b) Part B.--Section 1835(a)(2)(A)(iv) of the Social 
     Security Act, as added by section 6407(a)(2), is amended by 
     inserting ``, or a nurse practitioner or clinical nurse 
     specialist (as those terms are defined in section 
     1861(aa)(5)) who is working in collaboration with the 
     physician in accordance with State law, or a certified nurse-
     midwife (as defined in section 1861(gg)) as authorized by 
     State law, or a physician assistant (as defined in section 
     1861(aa)(5)) under the supervision of the physician,'' after 
     ``must document that the physician''.

     SEC. 10606. HEALTH CARE FRAUD ENFORCEMENT.

       (a) Fraud Sentencing Guidelines.--
       (1) Definition.--In this subsection, the term ``Federal 
     health care offense'' has the meaning given that term in 
     section 24 of title 18, United States Code, as amended by 
     this Act.
       (2) Review and amendments.--Pursuant to the authority under 
     section 994 of title 28, United States Code, and in 
     accordance with this subsection, the United States Sentencing 
     Commission shall--
       (A) review the Federal Sentencing Guidelines and policy 
     statements applicable to persons convicted of Federal health 
     care offenses;
       (B) amend the Federal Sentencing Guidelines and policy 
     statements applicable to persons convicted of Federal health 
     care offenses involving Government health care programs to 
     provide that the aggregate dollar amount of fraudulent bills 
     submitted to the Government health care program shall 
     constitute prima facie evidence of the amount of the intended 
     loss by the defendant; and
       (C) amend the Federal Sentencing Guidelines to provide--
       (i) a 2-level increase in the offense level for any 
     defendant convicted of a Federal health care offense relating 
     to a Government health care program which involves a loss of 
     not less than $1,000,000 and less than $7,000,000;
       (ii) a 3-level increase in the offense level for any 
     defendant convicted of a Federal health care offense relating 
     to a Government health care program which involves a loss of 
     not less than $7,000,000 and less than $20,000,000;
       (iii) a 4-level increase in the offense level for any 
     defendant convicted of a Federal health care offense relating 
     to a Government health care program which involves a loss of 
     not less than $20,000,000; and
       (iv) if appropriate, otherwise amend the Federal Sentencing 
     Guidelines and policy statements applicable to persons 
     convicted of Federal health care offenses involving 
     Government health care programs.
       (3) Requirements.--In carrying this subsection, the United 
     States Sentencing Commission shall--
       (A) ensure that the Federal Sentencing Guidelines and 
     policy statements--

[[Page 32787]]

       (i) reflect the serious harms associated with health care 
     fraud and the need for aggressive and appropriate law 
     enforcement action to prevent such fraud; and
       (ii) provide increased penalties for persons convicted of 
     health care fraud offenses in appropriate circumstances;
       (B) consult with individuals or groups representing health 
     care fraud victims, law enforcement officials, the health 
     care industry, and the Federal judiciary as part of the 
     review described in paragraph (2);
       (C) ensure reasonable consistency with other relevant 
     directives and with other guidelines under the Federal 
     Sentencing Guidelines;
       (D) account for any aggravating or mitigating circumstances 
     that might justify exceptions, including circumstances for 
     which the Federal Sentencing Guidelines, as in effect on the 
     date of enactment of this Act, provide sentencing 
     enhancements;
       (E) make any necessary conforming changes to the Federal 
     Sentencing Guidelines; and
       (F) ensure that the Federal Sentencing Guidelines 
     adequately meet the purposes of sentencing.
       (b) Intent Requirement for Health Care Fraud.--Section 1347 
     of title 18, United States Code, is amended--
       (1) by inserting ``(a)'' before ``Whoever knowingly''; and
       (2) by adding at the end the following:
       ``(b) With respect to violations of this section, a person 
     need not have actual knowledge of this section or specific 
     intent to commit a violation of this section.''.
       (c) Health Care Fraud Offense.--Section 24(a) of title 18, 
     United States Code, is amended--
       (1) in paragraph (1), by striking the semicolon and 
     inserting ``or section 1128B of the Social Security Act (42 
     U.S.C. 1320a-7b); or''; and
       (2) in paragraph (2)--
       (A) by inserting ``1349,'' after ``1343,''; and
       (B) by inserting ``section 301 of the Federal Food, Drug, 
     and Cosmetic Act (21 U.S.C. 331), or section 501 of the 
     Employee Retirement Income Security Act of 1974 (29 U.S.C. 
     1131),'' after ``title,''.
       (d) Subpoena Authority Relating to Health Care.--
       (1) Subpoenas under the health insurance portability and 
     accountability act of 1996.--Section 1510(b) of title 18, 
     United States Code, is amended--
       (A) in paragraph (1), by striking ``to the grand jury''; 
     and
       (B) in paragraph (2)--
       (i) in subparagraph (A), by striking ``grand jury 
     subpoena'' and inserting ``subpoena for records''; and
       (ii) in the matter following subparagraph (B), by striking 
     ``to the grand jury''.
       (2) Subpoenas under the civil rights of institutionalized 
     persons act.--The Civil Rights of Institutionalized Persons 
     Act (42 U.S.C. 1997 et seq.) is amended by inserting after 
     section 3 the following:

     ``SEC. 3A. SUBPOENA AUTHORITY.

       ``(a) Authority.--The Attorney General, or at the direction 
     of the Attorney General, any officer or employee of the 
     Department of Justice may require by subpoena access to any 
     institution that is the subject of an investigation under 
     this Act and to any document, record, material, file, report, 
     memorandum, policy, procedure, investigation, video or audio 
     recording, or quality assurance report relating to any 
     institution that is the subject of an investigation under 
     this Act to determine whether there are conditions which 
     deprive persons residing in or confined to the institution of 
     any rights, privileges, or immunities secured or protected by 
     the Constitution or laws of the United States.
       ``(b) Issuance and Enforcement of Subpoenas.--
       ``(1) Issuance.--Subpoenas issued under this section--
       ``(A) shall bear the signature of the Attorney General or 
     any officer or employee of the Department of Justice as 
     designated by the Attorney General; and
       ``(B) shall be served by any person or class of persons 
     designated by the Attorney General or a designated officer or 
     employee for that purpose.
       ``(2) Enforcement.--In the case of contumacy or failure to 
     obey a subpoena issued under this section, the United States 
     district court for the judicial district in which the 
     institution is located may issue an order requiring 
     compliance. Any failure to obey the order of the court may be 
     punished by the court as a contempt that court.
       ``(c) Protection of Subpoenaed Records and Information.--
     Any document, record, material, file, report, memorandum, 
     policy, procedure, investigation, video or audio recording, 
     or quality assurance report or other information obtained 
     under a subpoena issued under this section--
       ``(1) may not be used for any purpose other than to protect 
     the rights, privileges, or immunities secured or protected by 
     the Constitution or laws of the United States of persons who 
     reside, have resided, or will reside in an institution;
       ``(2) may not be transmitted by or within the Department of 
     Justice for any purpose other than to protect the rights, 
     privileges, or immunities secured or protected by the 
     Constitution or laws of the United States of persons who 
     reside, have resided, or will reside in an institution; and
       ``(3) shall be redacted, obscured, or otherwise altered if 
     used in any publicly available manner so as to prevent the 
     disclosure of any personally identifiable information.''.

     SEC. 10607. STATE DEMONSTRATION PROGRAMS TO EVALUATE 
                   ALTERNATIVES TO CURRENT MEDICAL TORT 
                   LITIGATION.

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

     ``SEC. 399V-4. STATE DEMONSTRATION PROGRAMS TO EVALUATE 
                   ALTERNATIVES TO CURRENT MEDICAL TORT 
                   LITIGATION.

       ``(a) In General.--The Secretary is authorized to award 
     demonstration grants to States for the development, 
     implementation, and evaluation of alternatives to current 
     tort litigation for resolving disputes over injuries 
     allegedly caused by health care providers or health care 
     organizations. In awarding such grants, the Secretary shall 
     ensure the diversity of the alternatives so funded.
       ``(b) Duration.--The Secretary may award grants under 
     subsection (a) for a period not to exceed 5 years.
       ``(c) Conditions for Demonstration Grants.--
       ``(1) Requirements.--Each State desiring a grant under 
     subsection (a) shall develop an alternative to current tort 
     litigation that--
       ``(A) allows for the resolution of disputes over injuries 
     allegedly caused by health care providers or health care 
     organizations; and
       ``(B) promotes a reduction of health care errors by 
     encouraging the collection and analysis of patient safety 
     data related to disputes resolved under subparagraph (A) by 
     organizations that engage in efforts to improve patient 
     safety and the quality of health care.
       ``(2) Alternative to current tort litigation.--Each State 
     desiring a grant under subsection (a) shall demonstrate how 
     the proposed alternative described in paragraph (1)(A)--
       ``(A) makes the medical liability system more reliable by 
     increasing the availability of prompt and fair resolution of 
     disputes;
       ``(B) encourages the efficient resolution of disputes;
       ``(C) encourages the disclosure of health care errors;
       ``(D) enhances patient safety by detecting, analyzing, and 
     helping to reduce medical errors and adverse events;
       ``(E) improves access to liability insurance;
       ``(F) fully informs patients about the differences in the 
     alternative and current tort litigation;
       ``(G) provides patients the ability to opt out of or 
     voluntarily withdraw from participating in the alternative at 
     any time and to pursue other options, including litigation, 
     outside the alternative;
       ``(H) would not conflict with State law at the time of the 
     application in a way that would prohibit the adoption of an 
     alternative to current tort litigation; and
       ``(I) would not limit or curtail a patient's existing legal 
     rights, ability to file a claim in or access a State's legal 
     system, or otherwise abrogate a patient's ability to file a 
     medical malpractice claim.
       ``(3) Sources of compensation.--Each State desiring a grant 
     under subsection (a) shall identify the sources from and 
     methods by which compensation would be paid for claims 
     resolved under the proposed alternative to current tort 
     litigation, which may include public or private funding 
     sources, or a combination of such sources. Funding methods 
     shall to the extent practicable provide financial incentives 
     for activities that improve patient safety.
       ``(4) Scope.--
       ``(A) In general.--Each State desiring a grant under 
     subsection (a) shall establish a scope of jurisdiction (such 
     as Statewide, designated geographic region, a designated area 
     of health care practice, or a designated group of health care 
     providers or health care organizations) for the proposed 
     alternative to current tort litigation that is sufficient to 
     evaluate the effects of the alternative. No scope of 
     jurisdiction shall be established under this paragraph that 
     is based on a health care payer or patient population.
       ``(B) Notification of patients.--A State shall demonstrate 
     how patients would be notified that they are receiving health 
     care services that fall within such scope, and the process by 
     which they may opt out of or voluntarily withdraw from 
     participating in the alternative. The decision of the patient 
     whether to participate or continue participating in the 
     alternative process shall be made at any time and shall not 
     be limited in any way.
       ``(5) Preference in awarding demonstration grants.--In 
     awarding grants under subsection (a), the Secretary shall 
     give preference to States--
       ``(A) that have developed the proposed alternative through 
     substantive consultation with relevant stakeholders, 
     including patient advocates, health care providers and health 
     care organizations, attorneys with expertise in representing 
     patients and health care providers, medical malpractice 
     insurers, and patient safety experts;

[[Page 32788]]

       ``(B) that make proposals that are likely to enhance 
     patient safety by detecting, analyzing, and helping to reduce 
     medical errors and adverse events; and
       ``(C) that make proposals that are likely to improve access 
     to liability insurance.
       ``(d) Application.--
       ``(1) In general.--Each State desiring a grant under 
     subsection (a) shall submit to the Secretary an application, 
     at such time, in such manner, and containing such information 
     as the Secretary may require.
       ``(2) Review panel.--
       ``(A) In general.--In reviewing applications under 
     paragraph (1), the Secretary shall consult with a review 
     panel composed of relevant experts appointed by the 
     Comptroller General.
       ``(B) Composition.--
       ``(i) Nominations.--The Comptroller General shall solicit 
     nominations from the public for individuals to serve on the 
     review panel.
       ``(ii) Appointment.--The Comptroller General shall appoint, 
     at least 9 but not more than 13, highly qualified and 
     knowledgeable individuals to serve on the review panel and 
     shall ensure that the following entities receive fair 
     representation on such panel:

       ``(I) Patient advocates.
       ``(II) Health care providers and health care organizations.
       ``(III) Attorneys with expertise in representing patients 
     and health care providers.
       ``(IV) Medical malpractice insurers.
       ``(V) State officials.
       ``(VI) Patient safety experts.

       ``(C) Chairperson.--The Comptroller General, or an 
     individual within the Government Accountability Office 
     designated by the Comptroller General, shall be the 
     chairperson of the review panel.
       ``(D) Availability of information.--The Comptroller General 
     shall make available to the review panel such information, 
     personnel, and administrative services and assistance as the 
     review panel may reasonably require to carry out its duties.
       ``(E) Information from agencies.--The review panel may 
     request directly from any department or agency of the United 
     States any information that such panel considers necessary to 
     carry out its duties. To the extent consistent with 
     applicable laws and regulations, the head of such department 
     or agency shall furnish the requested information to the 
     review panel.
       ``(e) Reports.--
       ``(1) By state.--Each State receiving a grant under 
     subsection (a) shall submit to the Secretary an annual report 
     evaluating the effectiveness of activities funded with grants 
     awarded under such subsection. Such report shall, at a 
     minimum, include the impact of the activities funded on 
     patient safety and on the availability and price of medical 
     liability insurance.
       ``(2) By secretary.--The Secretary shall submit to Congress 
     an annual compendium of the reports submitted under paragraph 
     (1) and an analysis of the activities funded under subsection 
     (a) that examines any differences that result from such 
     activities in terms of the quality of care, number and nature 
     of medical errors, medical resources used, length of time for 
     dispute resolution, and the availability and price of 
     liability insurance.
       ``(f) Technical Assistance.--
       ``(1) In general.--The Secretary shall provide technical 
     assistance to the States applying for or awarded grants under 
     subsection (a).
       ``(2) Requirements.--Technical assistance under paragraph 
     (1) shall include--
       ``(A) guidance on non-economic damages, including the 
     consideration of individual facts and circumstances in 
     determining appropriate payment, guidance on identifying 
     avoidable injuries, and guidance on disclosure to patients of 
     health care errors and adverse events; and
       ``(B) the development, in consultation with States, of 
     common definitions, formats, and data collection 
     infrastructure for States receiving grants under this section 
     to use in reporting to facilitate aggregation and analysis of 
     data both within and between States.
       ``(3) Use of common definitions, formats, and data 
     collection infrastructure.--States not receiving grants under 
     this section may also use the common definitions, formats, 
     and data collection infrastructure developed under paragraph 
     (2)(B).
       ``(g) Evaluation.--
       ``(1) In general.--The Secretary, in consultation with the 
     review panel established under subsection (d)(2), shall enter 
     into a contract with an appropriate research organization to 
     conduct an overall evaluation of the effectiveness of grants 
     awarded under subsection (a) and to annually prepare and 
     submit a report to Congress. Such an evaluation shall begin 
     not later than 18 months following the date of implementation 
     of the first program funded by a grant under subsection (a).
       ``(2) Contents.--The evaluation under paragraph (1) shall 
     include--
       ``(A) an analysis of the effects of the grants awarded 
     under subsection (a) with regard to the measures described in 
     paragraph (3);
       ``(B) for each State, an analysis of the extent to which 
     the alternative developed under subsection (c)(1) is 
     effective in meeting the elements described in subsection 
     (c)(2);
       ``(C) a comparison among the States receiving grants under 
     subsection (a) of the effectiveness of the various 
     alternatives developed by such States under subsection 
     (c)(1);
       ``(D) a comparison, considering the measures described in 
     paragraph (3), of States receiving grants approved under 
     subsection (a) and similar States not receiving such grants; 
     and
       ``(E) a comparison, with regard to the measures described 
     in paragraph (3), of--
       ``(i) States receiving grants under subsection (a);
       ``(ii) States that enacted, prior to the date of enactment 
     of the Patient Protection and Affordable Care Act, any cap on 
     non-economic damages; and
       ``(iii) States that have enacted, prior to the date of 
     enactment of the Patient Protection and Affordable Care Act, 
     a requirement that the complainant obtain an opinion 
     regarding the merit of the claim, although the substance of 
     such opinion may have no bearing on whether the complainant 
     may proceed with a case.
       ``(3) Measures.--The evaluations under paragraph (2) shall 
     analyze and make comparisons on the basis of--
       ``(A) the nature and number of disputes over injuries 
     allegedly caused by health care providers or health care 
     organizations;
       ``(B) the nature and number of claims in which tort 
     litigation was pursued despite the existence of an 
     alternative under subsection (a);
       ``(C) the disposition of disputes and claims, including the 
     length of time and estimated costs to all parties;
       ``(D) the medical liability environment;
       ``(E) health care quality;
       ``(F) patient safety in terms of detecting, analyzing, and 
     helping to reduce medical errors and adverse events;
       ``(G) patient and health care provider and organization 
     satisfaction with the alternative under subsection (a) and 
     with the medical liability environment; and
       ``(H) impact on utilization of medical services, 
     appropriately adjusted for risk.
       ``(4) Funding.--The Secretary shall reserve 5 percent of 
     the amount appropriated in each fiscal year under subsection 
     (k) to carry out this subsection.
       ``(h) MedPAC and MACPAC Reports.--
       ``(1) MedPAC.--The Medicare Payment Advisory Commission 
     shall conduct an independent review of the alternatives to 
     current tort litigation that are implemented under grants 
     under subsection (a) to determine the impact of such 
     alternatives on the Medicare program under title XVIII of the 
     Social Security Act, and its beneficiaries.
       ``(2) MACPAC.--The Medicaid and CHIP Payment and Access 
     Commission shall conduct an independent review of the 
     alternatives to current tort litigation that are implemented 
     under grants under subsection (a) to determine the impact of 
     such alternatives on the Medicaid or CHIP programs under 
     titles XIX and XXI of the Social Security Act, and their 
     beneficiaries.
       ``(3) Reports.--Not later than December 31, 2016, the 
     Medicare Payment Advisory Commission and the Medicaid and 
     CHIP Payment and Access Commission shall each submit to 
     Congress a report that includes the findings and 
     recommendations of each respective Commission based on 
     independent reviews conducted under paragraphs (1) and (2), 
     including an analysis of the impact of the alternatives 
     reviewed on the efficiency and effectiveness of the 
     respective programs.
       ``(i) Option to Provide for Initial Planning Grants.--Of 
     the funds appropriated pursuant to subsection (k), the 
     Secretary may use a portion not to exceed $500,000 per State 
     to provide planning grants to such States for the development 
     of demonstration project applications meeting the criteria 
     described in subsection (c). In selecting States to receive 
     such planning grants, the Secretary shall give preference to 
     those States in which State law at the time of the 
     application would not prohibit the adoption of an alternative 
     to current tort litigation.
       ``(j) Definitions.--In this section:
       ``(1) Health care services.--The term `health care 
     services' means any services provided by a health care 
     provider, or by any individual working under the supervision 
     of a health care provider, that relate to--
       ``(A) the diagnosis, prevention, or treatment of any human 
     disease or impairment; or
       ``(B) the assessment of the health of human beings.
       ``(2) Health care organization.--The term `health care 
     organization' means any individual or entity which is 
     obligated to provide, pay for, or administer health benefits 
     under any health plan.
       ``(3) Health care provider.--The term `health care 
     provider' means any individual or entity--
       ``(A) licensed, registered, or certified under Federal or 
     State laws or regulations to provide health care services; or
       ``(B) required to be so licensed, registered, or certified 
     but that is exempted by other statute or regulation.
       ``(k) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section, 
     $50,000,000 for the 5-fiscal year period beginning with 
     fiscal year 2011.
       ``(l) Current State Efforts to Establish Alternative to 
     Tort Litigation.--Nothing

[[Page 32789]]

     in this section shall be construed to limit any prior, 
     current, or future efforts of any State to establish any 
     alternative to tort litigation.
       ``(m) Rule of Construction.--Nothing in this section shall 
     be construed as limiting states' authority over or 
     responsibility for their state justice systems.''.

     SEC. 10608. EXTENSION OF MEDICAL MALPRACTICE COVERAGE TO FREE 
                   CLINICS.

       (a) In General.--Section 224(o)(1) of the Public Health 
     Service Act (42 U.S.C. 233(o)(1)) is amended by inserting 
     after ``to an individual'' the following: ``, or an officer, 
     governing board member, employee, or contractor of a free 
     clinic shall in providing services for the free clinic,''.
       (b) Effective Date.--The amendment made by this section 
     shall take effect on the date of enactment of this Act and 
     apply to any act or omission which occurs on or after that 
     date.

     SEC. 10609. LABELING CHANGES.

       Section 505(j) of the Federal Food, Drug, and Cosmetic Act 
     (21 U.S.C. 355(j)) is amended by adding at the end the 
     following:
       ``(10)(A) If the proposed labeling of a drug that is the 
     subject of an application under this subsection differs from 
     the listed drug due to a labeling revision described under 
     clause (i), the drug that is the subject of such application 
     shall, notwithstanding any other provision of this Act, be 
     eligible for approval and shall not be considered misbranded 
     under section 502 if--
       ``(i) the application is otherwise eligible for approval 
     under this subsection but for expiration of patent, an 
     exclusivity period, or of a delay in approval described in 
     paragraph (5)(B)(iii), and a revision to the labeling of the 
     listed drug has been approved by the Secretary within 60 days 
     of such expiration;
       ``(ii) the labeling revision described under clause (i) 
     does not include a change to the `Warnings' section of the 
     labeling;
       ``(iii) the sponsor of the application under this 
     subsection agrees to submit revised labeling of the drug that 
     is the subject of such application not later than 60 days 
     after the notification of any changes to such labeling 
     required by the Secretary; and
       ``(iv) such application otherwise meets the applicable 
     requirements for approval under this subsection.
       ``(B) If, after a labeling revision described in 
     subparagraph (A)(i), the Secretary determines that the 
     continued presence in interstate commerce of the labeling of 
     the listed drug (as in effect before the revision described 
     in subparagraph (A)(i)) adversely impacts the safe use of the 
     drug, no application under this subsection shall be eligible 
     for approval with such labeling.''.

             Subtitle G--Provisions Relating to Title VIII

     SEC. 10801. PROVISIONS RELATING TO TITLE VIII.

       (a) Title XXXII of the Public Health Service Act, as added 
     by section 8002(a)(1), is amended--
       (1) in section 3203--
       (A) in subsection (a)(1), by striking subparagraph (E);
       (B) in subsection (b)(1)(C)(i), by striking ``for 
     enrollment'' and inserting ``for reenrollment''; and
       (C) in subsection (c)(1), by striking ``, as part of their 
     automatic enrollment in the CLASS program,''; and
       (2) in section 3204--
       (A) in subsection (c)(2), by striking subparagraph (A) and 
     inserting the following:
       ``(A) receives wages or income on which there is imposed a 
     tax under section 3101(a) or 3201(a) of the Internal Revenue 
     Code of 1986; or'';
       (B) in subsection (d), by striking ``subparagraph (B) or 
     (C) of subsection (c)(1)'' and inserting ``subparagraph (A) 
     or (B) of subsection (c)(2)'';
       (C) in subsection (e)(2)(A), by striking ``subparagraph 
     (A)'' and inserting ``paragraph (1)''; and
       (D) in subsection (g)(1), by striking ``has elected to 
     waive enrollment'' and inserting ``has not enrolled''.
       (b) Section 8002 of this Act is amended in the heading for 
     subsection (d), by striking ``Information on Supplemental 
     Coverage'' and inserting ``CLASS Program Information''.
       (c) Section 6021(d)(2)(A)(iv) of the Deficit Reduction Act 
     of 2005, as added by section 8002(d) of this Act, is amended 
     by striking ``and coverage available'' and all that follows 
     through ``that program,''.

              Subtitle H--Provisions Relating to Title IX

     SEC. 10901. MODIFICATIONS TO EXCISE TAX ON HIGH COST 
                   EMPLOYER-SPONSORED HEALTH COVERAGE.

       (a) Longshore Workers Treated as Employees Engaged in High-
     Risk Professions.--Paragraph (3) of section 4980I(f) of the 
     Internal Revenue Code of 1986, as added by section 9001 of 
     this Act, is amended by inserting ``individuals whose primary 
     work is longshore work (as defined in section 258(b) of the 
     Immigration and Nationality Act (8 U.S.C. 1288(b)), 
     determined without regard to paragraph (2) thereof),'' before 
     ``and individuals engaged in the construction, mining''.
       (b) Exemption From High-Cost Insurance Tax Includes Certain 
     Additional Excepted Benefits.--Clause (i) of section 
     4980I(d)(1)(B) of the Internal Revenue Code of 1986, as added 
     by section 9001 of this Act, is amended by striking ``section 
     9832(c)(1)(A)'' and inserting ``section 9832(c)(1) (other 
     than subparagraph (G) thereof)''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2012.

     SEC. 10902. INFLATION ADJUSTMENT OF LIMITATION ON HEALTH 
                   FLEXIBLE SPENDING ARRANGEMENTS UNDER CAFETERIA 
                   PLANS.

       (a) In General.--Subsection (i) of section 125 of the 
     Internal Revenue Code of 1986, as added by section 9005 of 
     this Act, is amended to read as follows:
       ``(i) Limitation on Health Flexible Spending 
     Arrangements.--
       ``(1) In general.--For purposes of this section, if a 
     benefit is provided under a cafeteria plan through employer 
     contributions to a health flexible spending arrangement, such 
     benefit shall not be treated as a qualified benefit unless 
     the cafeteria plan provides that an employee may not elect 
     for any taxable year to have salary reduction contributions 
     in excess of $2,500 made to such arrangement.
       ``(2) Adjustment for inflation.--In the case of any taxable 
     year beginning after December 31, 2011, the dollar amount in 
     paragraph (1) shall be increased by an amount equal to--
       ``(A) such amount, multiplied by
       ``(B) the cost-of-living adjustment determined under 
     section 1(f)(3) for the calendar year in which such taxable 
     year begins by substituting `calendar year 2010' for 
     `calendar year 1992' in subparagraph (B) thereof.
     If any increase determined under this paragraph is not a 
     multiple of $50, such increase shall be rounded to the next 
     lowest multiple of $50.''.
       (b) Effective Date.--The amendment made by this section 
     shall apply to taxable years beginning after December 31, 
     2010.

     SEC. 10903. MODIFICATION OF LIMITATION ON CHARGES BY 
                   CHARITABLE HOSPITALS.

       (a) In General.--Subparagraph (A) of section 501(r)(5) of 
     the Internal Revenue Code of 1986, as added by section 9007 
     of this Act, is amended by striking ``the lowest amounts 
     charged'' and inserting ``the amounts generally billed''.
       (b) Effective Date.--The amendment made by this section 
     shall apply to taxable years beginning after the date of the 
     enactment of this Act.

     SEC. 10904. MODIFICATION OF ANNUAL FEE ON MEDICAL DEVICE 
                   MANUFACTURERS AND IMPORTERS.

       (a) In General.--Section 9009 of this Act is amended--
       (1) by striking ``2009'' in subsection (a)(1) and inserting 
     ``2010'',
       (2) by inserting ``($3,000,000,000 after 2017)'' after 
     ``$2,000,000,000'', and
       (3) by striking ``2008'' in subsection (i) and inserting 
     ``2009''.
       (b) Effective Date.--The amendments made by this section 
     shall take effect as if included in the enactment of section 
     9009.

     SEC. 10905. MODIFICATION OF ANNUAL FEE ON HEALTH INSURANCE 
                   PROVIDERS.

       (a) Determination of Fee Amount.--Subsection (b) of section 
     9010 of this Act is amended to read as follows:
       ``(b) Determination of Fee Amount.--
       ``(1) In general.--With respect to each covered entity, the 
     fee under this section for any calendar year shall be equal 
     to an amount that bears the same ratio to the applicable 
     amount as--
       ``(A) the covered entity's net premiums written with 
     respect to health insurance for any United States health risk 
     that are taken into account during the preceding calendar 
     year, bears to
       ``(B) the aggregate net premiums written with respect to 
     such health insurance of all covered entities that are taken 
     into account during such preceding calendar year.
       ``(2) Amounts taken into account.--For purposes of 
     paragraph (1), the net premiums written with respect to 
     health insurance for any United States health risk that are 
     taken into account during any calendar year with respect to 
     any covered entity shall be determined in accordance with the 
     following table:


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



[[Page 32790]]

       ``(3) Secretarial determination.--The Secretary shall 
     calculate the amount of each covered entity's fee for any 
     calendar year under paragraph (1). In calculating such 
     amount, the Secretary shall determine such covered entity's 
     net premiums written with respect to any United States health 
     risk on the basis of reports submitted by the covered entity 
     under subsection (g) and through the use of any other source 
     of information available to the Secretary.''.
       (b) Applicable Amount.--Subsection (e) of section 9010 of 
     this Act is amended to read as follows:
       ``(e) Applicable Amount.--For purposes of subsection 
     (b)(1), the applicable amount shall be determined in 
     accordance with the following table:


 
 
 
``Calendar year                          Applicable amount
  2011.................................  $2,000,000,000
  2012.................................  $4,000,000,000
  2013.................................  $7,000,000,000
  2014, 2015 and 2016..................  $9,000,000,000
  2017 and thereafter..................  $10,000,000,000.''.
 


       (c) Exemption From Annual Fee on Health Insurance for 
     Certain Nonprofit Entities.--Section 9010(c)(2) of this Act 
     is amended by striking ``or'' at the end of subparagraph (A), 
     by striking the period at the end of subparagraph (B) and 
     inserting a comma, and by adding at the end the following new 
     subparagraphs:
       ``(C) any entity--
       ``(i)(I) which is incorporated as, is a wholly owned 
     subsidiary of, or is a wholly owned affiliate of, a nonprofit 
     corporation under a State law, or
       ``(II) which is described in section 501(c)(4) of the 
     Internal Revenue Code of 1986 and the activities of which 
     consist of providing commercial-type insurance (within the 
     meaning of section 501(m) of such Code),
       ``(ii) the premium rate increases of which are regulated by 
     a State authority,
       ``(iii) which, as of the date of the enactment of this 
     section, acts as the insurer of last resort in the State and 
     is subject to State guarantee issue requirements, and
       ``(iv) for which the medical loss ratio (determined in a 
     manner consistent with the determination of such ratio under 
     section 2718(b)(1)(A) of the Public Health Service Act) with 
     respect to the individual insurance market for such entity 
     for the calendar year is not less than 100 percent,
       ``(D) any entity--
       ``(i)(I) which is incorporated as a nonprofit corporation 
     under a State law, or
       ``(II) which is described in section 501(c)(4) of the 
     Internal Revenue Code of 1986 and the activities of which 
     consist of providing commercial-type insurance (within the 
     meaning of section 501(m) of such Code), and
       ``(ii) for which the medical loss ratio (as so 
     determined)--

       ``(I) with respect to each of the individual, small group, 
     and large group insurance markets for such entity for the 
     calendar year is not less than 90 percent, and
       ``(II) with respect to all such markets for such entity for 
     the calendar year is not less than 92 percent, or

       ``(E) any entity--
       ``(i) which is a mutual insurance company,
       ``(ii) which for the period reported on the 2008 Accident 
     and Health Policy Experience Exhibit of the National 
     Association of Insurance Commissioners had--

       ``(I) a market share of the insured population of a State 
     of at least 40 but not more than 60 percent, and
       ``(II) with respect to all markets described in 
     subparagraph (D)(ii)(I), a medical loss ratio of not less 
     than 90 percent, and

       ``(iii) with respect to annual payment dates in calendar 
     years after 2011, for which the medical loss ratio 
     (determined in a manner consistent with the determination of 
     such ratio under section 2718(b)(1)(A) of the Public Health 
     Service Act) with respect to all such markets for such entity 
     for the preceding calendar year is not less than 89 percent 
     (except that with respect to such annual payment date for 
     2012, the calculation under 2718(b)(1)(B)(ii) of such Act is 
     determined by reference to the previous year, and with 
     respect to such annual payment date for 2013, such 
     calculation is determined by reference to the average for the 
     previous 2 years).''.
       (d) Certain Insurance Exempted From Fee.--Paragraph (3) of 
     section 9010(h) of this Act is amended to read as follows:
       ``(3) Health insurance.--The term `health insurance' shall 
     not include--
       ``(A) any insurance coverage described in paragraph (1)(A) 
     or (3) of section 9832(c) of the Internal Revenue Code of 
     1986,
       ``(B) any insurance for long-term care, or
       ``(C) any medicare supplemental health insurance (as 
     defined in section 1882(g)(1) of the Social Security Act).''.
       (e) Anti-Avoidance Guidance.--Subsection (i) of section 
     9010 of this Act is amended by inserting ``and shall 
     prescribe such regulations as are necessary or appropriate to 
     prevent avoidance of the purposes of this section, including 
     inappropriate actions taken to qualify as an exempt entity 
     under subsection (c)(2)'' after ``section''.
       (f) Conforming Amendments.--
       (1) Section 9010(a)(1) of this Act is amended by striking 
     ``2009'' and inserting ``2010''.
       (2) Section 9010(c)(2)(B) of this Act is amended by 
     striking ``(except'' and all that follows through ``1323)''.
       (3) Section 9010(c)(3) of this Act is amended by adding at 
     the end the following new sentence: ``If any entity described 
     in subparagraph (C)(i)(I), (D)(i)(I), or (E)(i) of paragraph 
     (2) is treated as a covered entity by reason of the 
     application of the preceding sentence, the net premiums 
     written with respect to health insurance for any United 
     States health risk of such entity shall not be taken into 
     account for purposes of this section.''.
       (4) Section 9010(g)(1) of this Act is amended by striking 
     ``and third party administration agreement fees''.
       (5) Section 9010(j) of this Act is amended--
       (A) by striking ``2008'' and inserting ``2009'', and
       (B) by striking ``, and any third party administration 
     agreement fees received after such date''.
       (g) Effective Date.--The amendments made by this section 
     shall take effect as if included in the enactment of section 
     9010.

     SEC. 10906. MODIFICATIONS TO ADDITIONAL HOSPITAL INSURANCE 
                   TAX ON HIGH-INCOME TAXPAYERS.

       (a) FICA.--Section 3101(b)(2) of the Internal Revenue Code 
     of 1986, as added by section 9015(a)(1) of this Act, is 
     amended by striking ``0.5 percent'' and inserting ``0.9 
     percent''.
       (b) SECA.--Section 1401(b)(2)(A) of the Internal Revenue 
     Code of 1986, as added by section 9015(b)(1) of this Act, is 
     amended by striking ``0.5 percent'' and inserting ``0.9 
     percent''.
       (c) Effective Date.--The amendments made by this section 
     shall apply with respect to remuneration received, and 
     taxable years beginning, after December 31, 2012.

     SEC. 10907. EXCISE TAX ON INDOOR TANNING SERVICES IN LIEU OF 
                   ELECTIVE COSMETIC MEDICAL PROCEDURES.

       (a) In General.--The provisions of, and amendments made by, 
     section 9017 of this Act are hereby deemed null, void, and of 
     no effect.
       (b) Excise Tax on Indoor Tanning Services.--Subtitle D of 
     the Internal Revenue Code of 1986, as amended by this Act, is 
     amended by adding at the end the following new chapter:

                    ``CHAPTER 49--COSMETIC SERVICES

``Sec. 5000B. Imposition of tax on indoor tanning services.

     ``SEC. 5000B. IMPOSITION OF TAX ON INDOOR TANNING SERVICES.

       ``(a) In General.--There is hereby imposed on any indoor 
     tanning service a tax equal to 10 percent of the amount paid 
     for such service (determined without regard to this section), 
     whether paid by insurance or otherwise.
       ``(b) Indoor Tanning Service.--For purposes of this 
     section--
       ``(1) In general.--The term `indoor tanning service' means 
     a service employing any electronic product designed to 
     incorporate 1 or more ultraviolet lamps and intended for the 
     irradiation of an individual by ultraviolet radiation, with 
     wavelengths in air between 200 and 400 nanometers, to induce 
     skin tanning.
       ``(2) Exclusion of phototherapy services.--Such term does 
     not include any phototherapy service performed by a licensed 
     medical professional.
       ``(c) Payment of Tax.--
       ``(1) In general.--The tax imposed by this section shall be 
     paid by the individual on whom the service is performed.
       ``(2) Collection.--Every person receiving a payment for 
     services on which a tax is imposed under subsection (a) shall 
     collect the amount of the tax from the individual on whom the 
     service is performed and remit such tax quarterly to the 
     Secretary at such time and in such manner as provided by the 
     Secretary.
       ``(3) Secondary liability.--Where any tax imposed by 
     subsection (a) is not paid at the time payments for indoor 
     tanning services are made, then to the extent that such tax 
     is not collected, such tax shall be paid by the person who 
     performs the service.''.
       (c) Clerical Amendment.--The table of chapter for subtitle 
     D of the Internal Revenue Code of 1986, as amended by this 
     Act, is amended by inserting after the item relating to 
     chapter 48 the following new item:

[[Page 32791]]

                   ``Chapter 49--Cosmetic Services''.

       (d) Effective Date.--The amendments made by this section 
     shall apply to services performed on or after July 1, 2010.

     SEC. 10908. EXCLUSION FOR ASSISTANCE PROVIDED TO PARTICIPANTS 
                   IN STATE STUDENT LOAN REPAYMENT PROGRAMS FOR 
                   CERTAIN HEALTH PROFESSIONALS.

       (a) In General.--Paragraph (4) of section 108(f) of the 
     Internal Revenue Code of 1986 is amended to read as follows:
       ``(4) Payments under national health service corps loan 
     repayment program and certain state loan repayment 
     programs.--In the case of an individual, gross income shall 
     not include any amount received under section 338B(g) of the 
     Public Health Service Act, under a State program described in 
     section 338I of such Act, or under any other State loan 
     repayment or loan forgiveness program that is intended to 
     provide for the increased availability of health care 
     services in underserved or health professional shortage areas 
     (as determined by such State).''.
       (b) Effective Date.--The amendment made by this section 
     shall apply to amounts received by an individual in taxable 
     years beginning after December 31, 2008.

     SEC. 10909. EXPANSION OF ADOPTION CREDIT AND ADOPTION 
                   ASSISTANCE PROGRAMS.

       (a) Increase in Dollar Limitation.--
       (1) Adoption credit.--
       (A) In general.--Paragraph (1) of section 23(b) of the 
     Internal Revenue Code of 1986 (relating to dollar limitation) 
     is amended by striking ``$10,000'' and inserting ``$13,170''.
       (B) Child with special needs.--Paragraph (3) of section 
     23(a) of such Code (relating to $10,000 credit for adoption 
     of child with special needs regardless of expenses) is 
     amended--
       (i) in the text by striking ``$10,000'' and inserting 
     ``$13,170'', and
       (ii) in the heading by striking ``$10,000'' and inserting 
     ``$13,170''.
       (C) Conforming amendment to inflation adjustment.--
     Subsection (h) of section 23 of such Code (relating to 
     adjustments for inflation) is amended to read as follows:
       ``(h) Adjustments for Inflation.--
       ``(1) Dollar limitations.--In the case of a taxable year 
     beginning after December 31, 2010, each of the dollar amounts 
     in subsections (a)(3) and (b)(1) shall be increased by an 
     amount equal to--
       ``(A) such dollar amount, multiplied by
       ``(B) the cost-of-living adjustment determined under 
     section 1(f)(3) for the calendar year in which the taxable 
     year begins, determined by substituting `calendar year 2009' 
     for `calendar year 1992' in subparagraph (B) thereof.
     If any amount as increased under the preceding sentence is 
     not a multiple of $10, such amount shall be rounded to the 
     nearest multiple of $10.
       ``(2) Income limitation.--In the case of a taxable year 
     beginning after December 31, 2002, the dollar amount in 
     subsection (b)(2)(A)(i) shall be increased by an amount equal 
     to--
       ``(A) such dollar amount, multiplied by
       ``(B) the cost-of-living adjustment determined under 
     section 1(f)(3) for the calendar year in which the taxable 
     year begins, determined by substituting `calendar year 2001' 
     for `calendar year 1992' in subparagraph (B) thereof.
     If any amount as increased under the preceding sentence is 
     not a multiple of $10, such amount shall be rounded to the 
     nearest multiple of $10.''.
       (2) Adoption assistance programs.--
       (A) In general.--Paragraph (1) of section 137(b) of the 
     Internal Revenue Code of 1986 (relating to dollar limitation) 
     is amended by striking ``$10,000'' and inserting ``$13,170''.
       (B) Child with special needs.--Paragraph (2) of section 
     137(a) of such Code (relating to $10,000 exclusion for 
     adoption of child with special needs regardless of expenses) 
     is amended--
       (i) in the text by striking ``$10,000'' and inserting 
     ``$13,170'', and
       (ii) in the heading by striking ``$10,000'' and inserting 
     ``$13,170''.
       (C) Conforming amendment to inflation adjustment.--
     Subsection (f) of section 137 of such Code (relating to 
     adjustments for inflation) is amended to read as follows:
       ``(f) Adjustments for Inflation.--
       ``(1) Dollar limitations.--In the case of a taxable year 
     beginning after December 31, 2010, each of the dollar amounts 
     in subsections (a)(2) and (b)(1) shall be increased by an 
     amount equal to--
       ``(A) such dollar amount, multiplied by
       ``(B) the cost-of-living adjustment determined under 
     section 1(f)(3) for the calendar year in which the taxable 
     year begins, determined by substituting `calendar year 2009' 
     for `calendar year 1992' in subparagraph (B) thereof.
     If any amount as increased under the preceding sentence is 
     not a multiple of $10, such amount shall be rounded to the 
     nearest multiple of $10.
       ``(2) Income limitation.--In the case of a taxable year 
     beginning after December 31, 2002, the dollar amount in 
     subsection (b)(2)(A) shall be increased by an amount equal 
     to--
       ``(A) such dollar amount, multiplied by
       ``(B) the cost-of-living adjustment determined under 
     section 1(f)(3) for the calendar year in which the taxable 
     year begins, determined by substituting `calendar year 2001' 
     for `calendar year 1992' in subparagraph thereof.
     If any amount as increased under the preceding sentence is 
     not a multiple of $10, such amount shall be rounded to the 
     nearest multiple of $10.''.
       (b) Credit Made Refundable.--
       (1) Credit moved to subpart relating to refundable 
     credits.--The Internal Revenue Code of 1986 is amended--
       (A) by redesignating section 23, as amended by subsection 
     (a), as section 36C, and
       (B) by moving section 36C (as so redesignated) from subpart 
     A of part IV of subchapter A of chapter 1 to the location 
     immediately before section 37 in subpart C of part IV of 
     subchapter A of chapter 1.
       (2) Conforming amendments.--
       (A) Section 24(b)(3)(B) of such Code is amended by striking 
     ``23,''.
       (B) Section 25(e)(1)(C) of such Code is amended by striking 
     ``23,'' both places it appears.
       (C) Section 25A(i)(5)(B) of such Code is amended by 
     striking ``23, 25D,'' and inserting ``25D''.
       (D) Section 25B(g)(2) of such Code is amended by striking 
     ``23,''.
       (E) Section 26(a)(1) of such Code is amended by striking 
     ``23,''.
       (F) Section 30(c)(2)(B)(ii) of such Code is amended by 
     striking ``23, 25D,'' and inserting ``25D''.
       (G) Section 30B(g)(2)(B)(ii) of such Code is amended by 
     striking ``23,''.
       (H) Section 30D(c)(2)(B)(ii) of such Code is amended by 
     striking ``sections 23 and'' and inserting ``section''.
       (I) Section 36C of such Code, as so redesignated, is 
     amended--
       (i) by striking paragraph (4) of subsection (b), and
       (ii) by striking subsection (c).
       (J) Section 137 of such Code is amended--
       (i) by striking ``section 23(d)'' in subsection (d) and 
     inserting ``section 36C(d)'', and
       (ii) by striking ``section 23'' in subsection (e) and 
     inserting ``section 36C''.
       (K) Section 904(i) of such Code is amended by striking 
     ``23,''.
       (L) Section 1016(a)(26) is amended by striking ``23(g)'' 
     and inserting ``36C(g)''.
       (M) Section 1400C(d) of such Code is amended by striking 
     ``23,''.
       (N) Section 6211(b)(4)(A) of such Code is amended by 
     inserting ``36C,'' before ``53(e)''.
       (O) The table of sections for subpart A of part IV of 
     subchapter A of chapter 1 of such Code of 1986 is amended by 
     striking the item relating to section 23.
       (P) Paragraph (2) of section 1324(b) of title 31, United 
     States Code, as amended by this Act, is amended by inserting 
     ``36C,'' after ``36B,''.
       (Q) The table of sections for subpart C of part IV of 
     subchapter A of chapter 1 of the Internal Revenue Code of 
     1986, as amended by this Act, is amended by inserting after 
     the item relating to section 36B the following new item:

``Sec. 36C. Adoption expenses.''.
       (c) Application and Extension of EGTRRA Sunset.--
     Notwithstanding section 901 of the Economic Growth and Tax 
     Relief Reconciliation Act of 2001, such section shall apply 
     to the amendments made by this section and the amendments 
     made by section 202 of such Act by substituting ``December 
     31, 2011'' for ``December 31, 2010'' in subsection (a)(1) 
     thereof.
       (d) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2009.
                                 ______
                                 
  SA 3277. Mr. REID proposed an amendment to amendment SA 3276 proposed 
by Mr. Reid (for himself, Mr. Baucus, Mr. Dodd, and Mr. Harkin) to the 
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; as follows:

       At the end of the amendment, add the following:
       The provisions of this Act shall become effective 5 days 
     after enactment.
                                 ______
                                 
  SA 3278. Mr. REID proposed an amendment 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; as follows:

       At the end of the language proposed to be stricken, insert 
     the following:
       This section shall become effective 4 days after enactment.
                                 ______
                                 
  SA 3279. Mr. REID proposed an amendment to amendment SA 3278 proposed 
by Mr. Reid 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

[[Page 32792]]

the Armed Forces and certain other Federal employees, and for other 
purposes; as follows:

       In the amendment, strike ``4'' and insert ``3''.
                                 ______
                                 
  SA 3280. Mr. REID proposed an amendment 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; as follows:

       At the end, insert the following:
       The provisions of this Act shall become effective 2 days 
     after enactment.
                                 ______
                                 
  SA 3281. Mr. REID proposed an amendment to amendment SA 3280 proposed 
by Mr. Reid 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; as follows:

       Strike ``2 days'' and insert ``1 day''.
                                 ______
                                 
  SA 3282. Mr. REID proposed an amendment to amendment SA 3281 proposed 
by Mr. Reid to the amendment SA 3280 proposed by Mr. Reid 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; as 
follows:

       Strike ``1 day'' and insert ``immediately''.
                                 ______
                                 
  SA 3283. Mr. COBURN 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:

       Strike all after the enacting clause and insert the 
     following:

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Patients' 
     Choice Act''.
       (b) Table of Contents.--The table of contents for this Act 
     is as follows:

Sec. 1. Short title; table of contents.

                    TITLE I--INVESTING IN PREVENTION

Sec. 101. Strategic approach to outcome-based prevention.
Sec. 102. State grants for outcome-based prevention effort.
Sec. 103. Focusing the food stamp program on nutrition.
Sec. 104. Immunizations.

              TITLE II--STATE-BASED HEALTH CARE EXCHANGES

Sec. 201. State-based health care exchanges.
Sec. 202. Requirements.
Sec. 203. State Exchange incentives.

 TITLE III--FAIR TAX TREATMENT FOR ALL AMERICANS TO AFFORD HEALTH CARE

Sec. 300. Reference.
Sec. 301. Refundable and advanceable credit for certain health 
              insurance coverage.
Sec. 302. Requiring employer transparency about employee benefits.
Sec. 303. Changes to existing tax preferences for medical coverage, 
              etc., for individuals eligible for qualified health 
              insurance credit.
Sec. 304. Adjustments.

             TITLE IV--FAIRNESS FOR EVERY AMERICAN PATIENT

                   Subtitle A--Medicaid Modernization

Sec. 401. Medicaid modernization.
Sec. 402. Outreach.
Sec. 403. Transition rules; miscellaneous provisions.

Subtitle B--Supplemental Health Care Assistance for Low-Income Families

Sec. 411. Supplemental Health Care Assistance for Low-Income Families.

             TITLE V--FIXING MEDICARE FOR AMERICAN SENIORS

     Subtitle A--Increasing Programmatic Efficiency, Economy, and 
                             Accountability

Sec. 501. Eliminating inefficiencies and increasing choice in Medicare 
              Advantage.
Sec. 502. Medicare Accountable Care Organization demonstration program.
Sec. 503. Reducing government handouts to wealthier seniors.
Sec. 504. Rewarding prevention.
Sec. 505. Promoting healthcare provider transparency.
Sec. 506. Availability of Medicare and Medicaid claims and patient 
              encounter data.

                  Subtitle B--Reducing Fraud and Abuse

Sec. 511. Requiring the Secretary of Health and Human Services to 
              change the Medicare beneficiary identifier used to 
              identify Medicare beneficiaries under the Medicare 
              program.
Sec. 512. Use of technology for real-time data review.
Sec. 513. Detection of medicare fraud and abuse.
Sec. 514. Edits on 855S Medicare enrollment application and exemption 
              of pharmacists from surety bond requirement.
Sec. 515. GAO study and report on effectiveness of surety bond 
              requirements for suppliers of durable medical equipment 
              in combating fraud.

                     TITLE VI--ENDING LAWSUIT ABUSE

Sec. 601. State grants to create health court solutions.

           TITLE VII--PROMOTING HEALTH INFORMATION TECHNOLOGY

 Subtitle A--Assisting the Development of Health Information Technology

Sec. 701. Purpose.
Sec. 702. Health record banking.
Sec. 703. Application of Federal and State security and confidentiality 
              standards.

    Subtitle B--Removing Barriers to the Use of Health Information 
              Technology to Better Coordinate Health Care

Sec. 711. Safe harbors to antikickback civil penalties and criminal 
              penalties for provision of health information technology 
              and training services.
Sec. 712. Exception to limitation on certain physician referrals (under 
              Stark) for provision of health information technology and 
              training services to health care professionals.
Sec. 713. Rules of construction regarding use of consortia.

              TITLE VIII--HEALTH CARE SERVICES COMMISSION

              Subtitle A--Establishment and General Duties

Sec. 801. Establishment.
Sec. 802. General authorities and duties.
Sec. 803. Dissemination.

     Subtitle B--Forum for Quality and Effectiveness in Health Care

Sec. 811. Establishment of office.
Sec. 812. Membership.
Sec. 813. Duties.
Sec. 814. Adoption and enforcement of guidelines and standards.
Sec. 815. Additional requirements.

                     Subtitle C--General Provisions

Sec. 821. Certain administrative authorities.
Sec. 822. Funding.
Sec. 823. Definitions.

                Subtitle D--Terminations and Transition

Sec. 831. Termination of Agency for Healthcare Research and Quality.
Sec. 832. Transition.

              Subtitle E--Independent Health Record Trust

Sec. 841. Short title.
Sec. 842. Purpose.
Sec. 843. Definitions.
Sec. 844. Establishment, certification, and membership of Independent 
              Health Record Trusts.
Sec. 845. Duties of IHRT to IHRT participants.
Sec. 846. Availability and use of information from records in IHRT 
              consistent with privacy protections and agreements.
Sec. 847. Voluntary nature of trust participation and information 
              sharing.
Sec. 848. Financing of activities.
Sec. 849. Regulatory oversight.

                        TITLE IX--MISCELLANEOUS

Sec. 901. Health care choice for veterans.
Sec. 902. Health care choice for Indians.
Sec. 903. Termination of Federal Coordinating Council for Comparative 
              Effectiveness Research.
Sec. 904. HHS and GAO joint study and report on costs of the 5 medical 
              conditions that have the greatest impact.
Sec. 905. Conscience protection.
Sec. 906. Nondiscrimination on abortion and respect for rights of 
              conscience
Sec. 907. Prohibition on government entities using comparative 
              effectiveness research for certain purposes.
Sec. 908. Solvency of Medicare program.
Sec. 909. To ensure patients receive doctor recommendations for 
              preventive health services, including mammograms and 
              cervical cancer screening, without interference from 
              government or insurance company bureaucrats.
Sec. 910. Ensuring that government health care rationing does not harm, 
              injure, or deny medically necessary care.
Sec. 911. Identification of Federal Government health care rationing.
Sec. 912. Using health care professionals to reduce fraud.

[[Page 32793]]



                    TITLE I--INVESTING IN PREVENTION

     SEC. 101. STRATEGIC APPROACH TO OUTCOME-BASED PREVENTION.

       (a) Interagency Coordinating Committee.--
       (1) In general.--The Secretary of Health and Human Services 
     (referred to in this title as the ``Secretary'') shall 
     convene an interagency coordinating committee to develop a 
     national strategic plan for prevention. The Secretary shall 
     serve as the chairperson of the committee.
       (2) Composition.--In carrying out paragraph (1), the 
     Secretary shall include the participation of--
       (A) the Director of the National Institutes of Health;
       (B) the Director of the Centers for Disease Control and 
     Prevention;
       (C) the Administrator of the Agency for Healthcare Research 
     and Quality;
       (D) the Administrator of the Substance Abuse and Mental 
     Health Services Administration;
       (E) the Administrator of the Health Resources and Services 
     Administration;
       (F) the Secretary of Agriculture;
       (G) the Director of the Centers for Medicare & Medicaid 
     Services;
       (H) the Administrator of the Environmental Protection 
     Agency;
       (I) the Director of the Indian Health Service;
       (J) the Administrator of the Administration on Aging;
       (K) the Secretary of Veterans Affairs;
       (L) the Secretary of Defense;
       (M) the Secretary of Education; and
       (N) the Secretary of Labor.
       (3) Report and plan.--Not later than 1 year after the date 
     of enactment of this Act, the Secretary, acting through the 
     coordinating committee convened under paragraph (1), shall 
     submit to Congress a report concerning the recommendation of 
     the committee for health promotion and disease prevention 
     activities. Such report shall include a specific strategic 
     plan that shall include--
       (A) a list of national priorities on health promotion and 
     disease prevention to address lifestyle behavior modification 
     (smoking cessation, proper nutrition, and appropriate 
     exercise) and the prevention measures for the 5 leading 
     disease killers in the United States;
       (B) specific science-based initiatives to achieve the 
     measurable goals of Healthy People 2010 regarding nutrition, 
     exercise, and smoking cessation, and targeting the 5 leading 
     disease killers in the United States;
       (C) specific plans for consolidating Federal health 
     programs and Centers that exist to promote healthy behavior 
     and reduce disease risk (including eliminating programs and 
     offices determined to be ineffective in meeting the priority 
     goals of Healthy People 2010), that include transferring the 
     nutrition guideline development responsibility from the 
     Secretary of Agriculture to the Director of the Centers for 
     Disease Control and Prevention;
       (D) specific plans to ensure that all Federal health care 
     programs are fully coordinated with science-based prevention 
     recommendations promulgated by the Director of the Centers 
     for Disease Control and Prevention;
       (E) specific plans to ensure that all non-Department of 
     Health and Human Services prevention programs are based on 
     the science-based guidelines developed by the Centers for 
     Disease Control and Prevention under subparagraph (D); and
       (F) a list of new non-Federal and non-government partners 
     identified by the committee to build Federal capacity in 
     health promotion and disease prevention efforts.
       (4) Annual request to give testimony.--The Secretary shall 
     annually request an opportunity to testify before Congress 
     concerning the progress made by the United States in meeting 
     the outcome-based standards of Healthy People 2010 with 
     respect to disease prevention and measurable outcomes and 
     effectiveness of Federal programs related to this goal.
       (5) Periodic reviews.--The Secretary shall conduct periodic 
     reviews, not less than every 5 years, and grading of every 
     Federal disease prevention and health promotion initiatives, 
     programs, and agencies. Such reviews shall be evaluated based 
     on effectiveness in meeting metrics-based goals with an 
     analysis posted on such agencies' public Internet websites.
       (b) Federal Messaging on Health Promotion and Disease 
     Prevention.--
       (1) Media campaigns.--
       (A) In general.--Not later than 1 year after the date of 
     enactment of this Act, the Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     shall establish and implement a national science-based media 
     campaign on health promotion and disease prevention.
       (B) Requirements of campaign.--The campaign implemented 
     under subparagraph (A)--
       (i) shall be designed to address proper nutrition, regular 
     exercise, smoking cessation, obesity reduction, the 5 leading 
     disease killers in the United States, and secondary 
     prevention through disease screening promotion;
       (ii) shall be carried out through competitively bid 
     contracts awarded to entities providing for the professional 
     production and design of such campaign;
       (iii) may include the use of television, radio, Internet, 
     and other commercial marketing venues and may be targeted to 
     specific age groups based on peer-reviewed social research;
       (iv) shall not be duplicative of any other Federal efforts 
     relating to health promotion and disease prevention; and
       (v) may include the use of humor and nationally recognized 
     positive role models.
       (C) Evaluation.--The Secretary shall ensure that the 
     campaign implemented under subparagraph (A) is subject to an 
     independent evaluation every 2 years and shall report every 2 
     years to Congress on the effectiveness of such campaigns 
     towards meeting science-based metrics.
       (2) Website.--The Secretary, in consultation with private-
     sector experts, shall maintain or enter into a contract to 
     maintain an Internet website to provide science-based 
     information on guidelines for nutrition, regular exercise, 
     obesity reduction, smoking cessation, and specific chronic 
     disease prevention. Such website shall be designed to provide 
     information to health care providers and consumers.
       (3) Dissemination of information through providers.--The 
     Secretary, acting through the Centers for Disease Control and 
     Prevention, shall develop and implement a plan for the 
     dissemination of health promotion and disease prevention 
     information consistent with national priorities described in 
     the strategic and implementing plan under subsection 
     (a)(3)(A), to health care providers who participate in 
     Federal programs, including programs administered by the 
     Indian Health Service, the Department of Veterans Affairs, 
     the Department of Defense, and the Health Resources and 
     Services Administration, and the Medicare and Medicaid 
     Programs.
       (4) Personalized prevention plans.--
       (A) Contract.--The Secretary, acting through the Director 
     of the Centers for Disease Control and Prevention, shall 
     enter into a contract with a qualified entity for the 
     development and operation of a Federal Internet website 
     personalized prevention plan tool.
       (B) Use.--The website developed under subparagraph (A) 
     shall be designed to be used as a source of the most up-to-
     date scientific evidence relating to disease prevention for 
     use by individuals. Such website shall contain a component 
     that enables an individual to determine their disease risk 
     (based on personal health and family history, BMI, and other 
     relevant information) relating to the 5 leading diseases in 
     the United States, and obtain personalized suggestions for 
     preventing such diseases.
       (5) Internet portal.--The Secretary shall establish an 
     Internet portal for accessing risk-assessment tools developed 
     and maintained by private and academic entities.
       (6) Priority funding.--Funding for the activities 
     authorized under this section shall take priority over 
     funding from the Centers for Disease Control and Prevention 
     provided for grants to States and other entities for similar 
     purposes and goals as provided for in this section. Not to 
     exceed $500,000,000 shall be expended on the campaigns and 
     activities required under this Act.

     SEC. 102. STATE GRANTS FOR OUTCOME-BASED PREVENTION EFFORT.

       (a) In General.--If the Secretary determines that it is 
     essential to meeting the national priorities described in the 
     plan required under section 101(a)(3)(A), the Secretary may 
     award grants to States for the conduct of specific health 
     promotion and disease prevention activities.
       (b) Eligibility.--To be eligible to receive a grant under 
     subsection (a), a State shall submit to the Secretary an 
     application at such time, in such manner, and containing such 
     information as the Secretary may require, including a 
     strategic plan that shall--
       (1) describe the specific health promotion and disease 
     prevention activities to be carried out under this grant;
       (2) include a list of the barriers that exist within the 
     State to meeting specific goals of Healthy People 2010;
       (3) include targeted demographic indicators and measurable 
     objectives with respect to health promotion and disease 
     prevention;
       (4) contain a set of process outcomes and milestones, based 
     on the process outcomes and milestones developed by the 
     Secretary, for measuring the effectiveness of activities 
     carried out under the grant in the State; and
       (5) outline the manner in which interventions to be carried 
     out under this grant will reduce morbidity and mortality 
     within the State over a 5-year period (or over a 10-year 
     period, if the Secretary determines such period appropriate 
     for adequately measuring progress).
       (c) Process Outcomes and Milestones.--
       (1) In general.--The Secretary shall develop process 
     outcomes and milestones to be used to measure the 
     effectiveness of activities carried out under a grant under 
     this section by a State.
       (2) Determinations.--If, beginning 2 years after the date 
     on which a grant is awarded to a State under this section, 
     the Secretary determines that the State is failing to make 
     adequate progress in meeting the outcomes and milestones 
     contained in the State plan under subsection (b)(4), the 
     Secretary shall provide the State with technical assistance

[[Page 32794]]

     on how to make such progress. Such technical assistance shall 
     continue for a period of 2 years.
       (3) Continued failure to meet objectives.--If after the 
     expiration of the 2-year period described in paragraph (2), 
     the Secretary determines that the State is failing to make 
     adequate progress in meeting the outcomes and milestones 
     contained in the State plan under subsection (b)(4) over a 5-
     year period, the Secretary shall terminate all funding to the 
     State under a grant under this section.
       (d) Regional Activities.--A State may use an amount, not to 
     exceed 15 percent of the total grant amount to such State, to 
     carry out regional activities in conjunction with other 
     States.
       (e) Targeted Activities.--A State may use grant funds to 
     target specific populations within the State to achieve 
     specific outcomes described in Healthy People 2010.
       (f) Innovative Incentive Structures.--The Secretary may 
     award grants to States for the purposes of developing 
     innovative incentive structures to encourage individuals to 
     adopt specific prevention behaviors such as reducing their 
     body mass index or for smoking cessation.
       (g) Wellness Bonuses.--
       (1) In general.--The Secretary shall award wellness bonus 
     payments to at least 5, but not more than 10, States that 
     demonstrate the greatest progress in reducing disease rates 
     and risk factors and increasing heathy behaviors.
       (2) Requirement.--To be eligible to receive a bonus payment 
     under paragraph (1), a State shall demonstrate--
       (A) the progress described in paragraph (1); and
       (B) that the State has met a specific floor for progress 
     outlined in the science-based metrics of Healthy People 2010.
       (3) Use of payments.--Bonus payments under this subsection 
     may only be used by a State for the purposes of health 
     promotion and disease prevention.
       (4) Funding.--Out of funds appropriated to the Director of 
     the Centers for Disease Control and Prevention for each 
     fiscal year beginning with fiscal year 2010, the Director 
     shall give priority to using $50,000,000 of such funds to 
     make bonus payments under this subsection.
       (h) Administrative Expenses.--A State may use not more than 
     5 percent of the amount of a grant under this section to 
     carry out administrative activities.
       (i) State.--In this section, the term ``State'' means the 
     50 States, the District of Columbia, the Commonwealth of 
     Puerto Rico, Guam, Samoa, the United States Virgin Islands, 
     and the Commonwealth of the Northern Mariana Islands.
       (j) Authorization of Appropriations.--Funding for the 
     activities authorized under this section shall take priority 
     over funding from the Centers for Disease Control and 
     Prevention provided for grants to States and other entities 
     for similar purposes and goals as provided for in this 
     section, not to exceed $300,000,000 for each fiscal year.

     SEC. 103. FOCUSING THE FOOD STAMP PROGRAM ON NUTRITION.

       (a) Counseling Brochure.--The Director of the Centers for 
     Disease Control and Prevention shall develop, and the 
     Secretary of Agriculture shall distribute to each individual 
     and family enrolled in the Food Stamp Program under the Food 
     Stamp Act of 1977 (7 U.S.C. 2011 et seq.), a science-based 
     nutrition counseling brochure.
       (b) Limitations on Food Stamp Purchases.--
       (1) In general.--Not later than 6 months after the date of 
     enactment of this Act, the Secretary of Agriculture shall, 
     based on scientific, peer-reviewed recommendations provided 
     by a Commission that includes public health, medical, and 
     nutrition experts and the Director of the Centers for Disease 
     Control and Prevention, develop lists of foods that do not 
     meet science-based standards for proper nutrition and that 
     may not be purchased under the food stamp program. Such list 
     shall be updated on an annual basis to ensure the most 
     current science-based recommendations are applied to the food 
     stamp program.
       (2) Automated enforcement.--The Secretary of Agriculture 
     shall, through regulations, ensure that the limitations on 
     food purchases under paragraph (1) is enforced through the 
     food stamp program's automated system.
       (3) Implementation.--The Secretary of Agriculture shall 
     promulgate the regulations described in paragraph (2) by the 
     date that is not later than 1 year after the date of 
     enactment of this section.

     SEC. 104. IMMUNIZATIONS.

       (a) Purchase of Vaccines.--Notwithstanding any other 
     provision of law, a State may use amounts provided under 
     section 317 of the Public Health Service Act (42 U.S.C. 247b) 
     for immunization programs to purchase vaccines for use in 
     health care provider offices and schools.
       (b) Technical Assistance and Reduction in Funding.--If a 
     State does not achieve a benchmark of 80 percent coverage 
     within the State for Centers for Disease Control and 
     Prevention-recommended vaccines, the Director of the Centers 
     shall provide technical assistance to the State for a period 
     of 2 years. If after the expiration of such 2-year period the 
     State continues to fail to achieve such benchmark, the 
     Secretary shall reduce funding provided under section 317 of 
     the Public Health Service Act to such State by 5 percent.
       (c) Bonus Grant.--A State achieving a benchmark of 90 
     percent or greater coverage within the State for Centers for 
     Disease Control and Prevention-recommended vaccines shall be 
     eligible for a bonus grant from amounts appropriated under 
     subsection (d).
       (d) Authorization of Appropriations.--Out of funds 
     appropriated to the Director of the Centers for Disease 
     Control and Prevention for each fiscal year beginning with 
     fiscal year 2010, there shall be made available to carry out 
     this section, $50,000,000 for each fiscal year.
       (e) Funding for Section 317.--Section 317(j)(1) of the 
     Public Health Service Act (42 U.S.C. 247b(j)(1)) is amended 
     by striking ``2005'' and inserting ``2012''.

              TITLE II--STATE-BASED HEALTH CARE EXCHANGES

     SEC. 201. STATE-BASED HEALTH CARE EXCHANGES.

       (a) In General.--The Secretary of Health and Human Services 
     (referred to in this title as the ``Secretary'') shall 
     establish a process for the review of applications submitted 
     by States for the establishment and implementation of State-
     based health care Exchanges (referred to in this title as a 
     ``State Exchange'') and for the certification of such 
     Exchanges. The Secretary shall certify a State Exchange if 
     the Secretary determines that such Exchange meets the 
     requirements of this title.
       (b) Continued Certification.--The certification of a State 
     Exchange under subsection (a) shall remain in effect until 
     the Secretary determines that the Exchange has failed to meet 
     any of the requirements under this title.

     SEC. 202. REQUIREMENTS.

       (a) General Requirements for Certification.--An application 
     for certification under section 201(a) shall demonstrate 
     compliance with the following:
       (1) Purpose.--The primary purpose of a State Exchange shall 
     be the facilitation of the individual purchase of innovative 
     private health insurance and the creation of a market where 
     private health plans compete for enrollees based on price and 
     quality.
       (2) Administration.--A State shall ensure the operation of 
     the State Exchange through direct contracts with the health 
     insurance plans that are participating in the State Exchange 
     or through a contract with a third party administrator for 
     the operation of the Exchange.
       (3) Plan participation.--A State shall not restrict or 
     otherwise limit the ability of a health insurance plan to 
     participate in, and offer health insurance coverage through, 
     the State Exchange, so long as the health insurance issuers 
     involved are duly licensed under State insurance laws 
     applicable to all health insurance issuers in the State and 
     otherwise comply with the requirements of this title.
       (4) Premiums.--
       (A) Amount.--A State shall not determine premium or cost 
     sharing amounts for health insurance coverage offered through 
     the State Exchange.
       (B) Collection method.--A State shall ensure the existence 
     of an effective and efficient method for the collection of 
     premiums for health insurance coverage offered through the 
     State Exchange.
       (b) Benefit Parity With Members of Congress.--With respect 
     to health insurance issuers offering health insurance 
     coverage through the State Exchange, the State shall not 
     impose any requirement that such issuers provide coverage 
     that includes benefits different than requirements on plans 
     offered to Members of Congress under chapter 89 of title 5, 
     United States Code.
       (c) Facilitating Universal Coverage for Americans.--
       (1) Automatic enrollment.--The State Exchange shall ensure 
     that health insurance coverage offered through the Exchange 
     provides for the application of uniform mechanisms that are 
     designed to encourage and facilitate the enrollment of all 
     eligible individuals in Exchange-based health insurance 
     coverage. Such mechanisms shall include automatic enrollment 
     through various venues, which may include emergency rooms, 
     the submission of State tax forms, places of employment in 
     the State, and State departments of motor vehicles.
       (2) Other enrollment opportunities.--
       (A) In general.--The State Exchange shall ensure that 
     health insurance coverage offered through the Exchange 
     permits enrollment, and changes in enrollment, of individuals 
     at the time such individuals become eligible individuals in 
     the State.
       (B) Annual open enrollment periods.--The State Exchange 
     shall ensure that health insurance coverage offered through 
     the Exchange permits eligible individuals to annually change 
     enrollment among the coverage offered through the Exchange, 
     subject to subparagraph (A).
       (C) Incentives for continuous annual coverage.--The State 
     Exchange shall include an incentive for eligible individuals 
     to remain insured from plan year to plan year, and may 
     include incentives such as State tax incentives or premium-
     based incentives.
       (3) Guaranteed access for individuals.--The State Exchange 
     shall ensure that, with

[[Page 32795]]

     respect to health insurance coverage offered through the 
     Exchange, all eligible individuals are able to enroll in the 
     coverage of their choice provided that such individuals agree 
     to make applicable premium and cost sharing payments.
       (4) Limitation on pre-existing condition exclusions.--The 
     State Exchange shall ensure that health insurance coverage 
     offered through the Exchange meets the requirements of 
     section 9801 of the Internal Revenue Code of 1986 in the same 
     manner as if such coverage was a group health plan.
       (5) Opt-out.--Nothing in this title shall be construed to 
     require that an individual be enrolled in health insurance 
     coverage.
       (d) Limitation on Exorbitant Premiums.--
       (1) Establishment of mechanism.--With respect to health 
     insurance coverage offered through the State Exchange, the 
     Exchange shall establish a mechanisms to protect enrollees 
     from the imposition of excessive premiums, to reduce adverse 
     selection, and to share risk.
       (2) Mechanism options.--The mechanisms referred to in 
     paragraph (1) may include the following:
       (A) Independent risk adjustment.--The implementation of 
     risk-adjustment among health insurance coverage offered 
     through the State Exchange through a contract entered into 
     with a private, independent board. Such board shall include 
     representation of health insurance issuers and State 
     officials but shall be independently controlled. The State 
     Exchange shall ensure that risk-adjustment implemented under 
     this subparagraph shall be based on a blend of patient 
     diagnoses and estimated costs.
       (B) Health security pools.--The establishment (or continued 
     operation under section 2745 of the Public Health Service 
     Act) of a health security pool to guarantee high-risk 
     individuals access to affordable, quality health care.
       (C) Reinsurance.--The implementation of a successful 
     reinsurance mechanisms to guarantee high-risk individuals 
     access to affordable, quality health care.
       (e) Medicaid and SCHIP Beneficiaries.--The State Exchange 
     shall include procedures to permit eligible individuals who 
     are receiving (or who are eligible to receive) health care 
     under title XIX or XXI of the Social Security Act to enroll 
     in health insurance coverage offered through the Exchange.
       (f) Dissemination of Coverage Information.--The State 
     Exchange shall ensure that each health insurance issuer that 
     provides health insurance coverage through the Exchange 
     disseminate to eligible individuals and employers within the 
     State information concerning health insurance coverage 
     options, including the plans offered and premiums and 
     benefits for such plans.
       (g) Regional Options.--
       (1) Interstate compacts.--Two or more States that establish 
     a State Exchange may enter into interstate compacts providing 
     for the regulations of health insurance coverage offered 
     within such States.
       (2) Model legislation.--States adopting model legislation 
     as developed by the National Association of Insurance 
     Commissioners shall be eligible to enter into an interstate 
     compact as provided for in this section.
       (3) Multi-state pooling arrangements.--State Exchanges may 
     implement a multi-state health care coverage pooling 
     arrangement under this title.
       (h) Purchase Across State Lines.--Notwithstanding any other 
     provision of law, an eligible individual may enroll in health 
     insurance coverage offered through the Exchange in any State. 
     The regulation of such coverage (and the addressing of 
     greviances relating to such coverage) shall be subject to the 
     laws of the State in which such coverage is purchased, 
     regardless of the State in which the eligible individual 
     resides.
       (i) Eligible Individual.--In this title, the term 
     ``eligible individual'' means an individual who is--
       (1) a citizen or national of the United States or an alien 
     lawfully admitted to the United States for permanent 
     residence or otherwise residing in the United States under 
     color of law;
       (2) not incarcerated; and
       (3) not eligible for coverage under parts A and B (or C) of 
     the Medicare program under title XVIII of the Social Security 
     Act.

     SEC. 203. STATE EXCHANGE INCENTIVES.

       (a) Grants.--The Secretary may award grants, pursuant to 
     subsection (b), to States for the development, 
     implementation, and evaluation of certified State Exchanges 
     and to provide more options and choice for individuals 
     purchasing health insurance coverage.
       (b) One-Time Increase in Medicaid Payment.--In the case of 
     a State awarded a grant to carry out this section, the total 
     amount of the Federal payment determined for the State under 
     section 1913 of the Social Security Act (as amended by 
     section 401) for fiscal year 2011 shall be increased by an 
     amount equal to 1 percent of the total amount of payments 
     made to the State for fiscal year 2010 under section 1903(a) 
     of the Social Security Act (42 U.S.C. 1396b(a)) for purposes 
     of carrying out a grant awarded under this section. Amounts 
     paid to a State pursuant to this subsection shall remain 
     available until expended.

 TITLE III--FAIR TAX TREATMENT FOR ALL AMERICANS TO AFFORD HEALTH CARE

     SEC. 300. REFERENCE.

       Except as otherwise expressly provided, whenever in this 
     title an amendment or repeal is expressed in terms of an 
     amendment to, or repeal of, a section or other provision, the 
     reference shall be considered to be made to a section or 
     other provision of the Internal Revenue Code of 1986.

     SEC. 301. REFUNDABLE AND ADVANCEABLE CREDIT FOR CERTAIN 
                   HEALTH INSURANCE COVERAGE.

       (a) Advanceable Credit.--Subpart A of part IV of subchapter 
     A of chapter 1 (relating to nonrefundable personal credits) 
     is amended by adding at the end the following new section:

     ``SEC. 25E. QUALIFIED HEALTH INSURANCE CREDIT.

       ``(a) Allowance of Credit.--In the case of an individual, 
     there shall be allowed as a credit against the tax imposed by 
     this chapter for the taxable year the sum of the monthly 
     limitations determined under subsection (b) for the taxpayer 
     and the taxpayer's spouse and dependents.
       ``(b) Monthly Limitation.--
       ``(1) In general.--The monthly limitation for each month 
     during the taxable year for an eligible individual is \1/
     12\th of--
       ``(A) the applicable adult amount, in the case that the 
     eligible individual is the taxpayer or the taxpayer's spouse,
       ``(B) the applicable adult amount, in the case that the 
     eligible individual is an adult dependent, and
       ``(C) the applicable child amount, in the case that the 
     eligible individual is a child dependent.
       ``(2) Limitation on aggregate amount.--Notwithstanding 
     paragraph (1), the aggregate monthly limitations for the 
     taxpayer and the taxpayer's spouse and dependents for any 
     month shall not exceed \1/12\th of the applicable aggregate 
     amount.
       ``(3) No credit for ineligible months.--With respect to any 
     individual, the monthly limitation shall be zero for any 
     month for which such individual is not an eligible 
     individual.
       ``(4) Applicable amount.--
       ``(A) In general.--For purposes of this section--
       ``(i) Applicable adult amount.--The applicable adult amount 
     is $2,290.
       ``(ii) Applicable child amount.--The applicable child 
     amount is $1,710.
       ``(iii) Applicable aggregate amount.--The applicable 
     aggregate amount is $5,710.
       ``(B) Cost-of-living adjustments.--
       ``(i) In general.--In the case of any taxable year 
     beginning in a calendar year after 2011, each dollar amount 
     contained in subparagraph (A) shall be increased by an amount 
     equal to such dollar amount multiplied by the blended cost-
     of-living adjustment.
       ``(ii) Blended cost-of-living adjustment.--For purposes of 
     clause (i), the blended cost-of-living adjustment means one-
     half of the sum of--

       ``(I) the cost-of-living adjustment determined under 
     section 1(f)(3) for the calendar year in which the taxable 
     year begins by substituting `calendar year 2010' for 
     `calendar year 1992' in subparagraph (B) thereof, plus
       ``(II) the cost-of-living adjustment determined under 
     section 213(d)(10)(B)(ii) for the calendar year in which the 
     taxable year begins by substituting `2010' for `1996' in 
     subclause (II) thereof.

       ``(iii) Rounding.--Any increase determined under clause (i) 
     shall be rounded to the nearest multiple of $10.
       ``(C) Revenue neutrality adjustments.--
       ``(i) In general.--In the case of any taxable year 
     beginning in a calendar year after 2011, each dollar amount 
     contained in subparagraph (A), as adjusted under subparagraph 
     (B), shall be further adjusted (if necessary) such that the 
     aggregate of such dollar amounts allowed as credits under 
     this section for such taxable year equals but does not exceed 
     the total increase in revenues in the Treasury resulting from 
     the amendments made by sections 303 and 401 of the Patients' 
     Choice Act for such taxable year as estimated by the 
     Secretary.
       ``(ii) Date of adjustment.--The Secretary shall announce 
     the adjustments for any taxable year under this subparagraph 
     not later than the preceding October 1.
       ``(c) Limitation Based on Amount of Tax.--In the case of a 
     taxable year to which section 26(a)(2) does not apply, the 
     credit allowed under subsection (a) for the taxable year 
     shall not exceed the excess of--
       ``(1) the sum of the regular tax liability (as defined in 
     section 26(b)) plus the tax imposed by section 55, over
       ``(2) the sum of the credits allowable under this subpart 
     (other than this section) and section 27 for the taxable 
     year.
       ``(d) Excess Credit Refundable to Certain Tax-Favored 
     Accounts.--If--
       ``(1) the credit which would be allowable under subsection 
     (a) if only qualified refund eligible health insurance were 
     taken into account under this section, exceeds
       ``(2) the limitation imposed by section 26 or subsection 
     (c) for the taxable year,
     such excess shall be paid by the Secretary into the 
     designated account of the taxpayer.
       ``(e) Eligible Individual.--For purposes of this section--

[[Page 32796]]

       ``(1) In general.--The term `eligible individual' means, 
     with respect to any month, an individual who--
       ``(A) is the taxpayer, the taxpayer's spouse, or the 
     taxpayer's dependent, and
       ``(B) is covered under qualified health insurance as of the 
     1st day of such month.
       ``(2) Medicare coverage, medicaid disability coverage, and 
     military coverage.--The term `eligible individual' shall not 
     include any individual who for any month is--
       ``(A) entitled to benefits under part A of title XVIII of 
     the Social Security Act or enrolled under part B of such 
     title, and the individual is not a participant or beneficiary 
     in a group health plan or large group health plan that is a 
     primary plan (as defined in section 1862(b)(2)(A) of such 
     Act),
       ``(B) enrolled by reason of disability in the program under 
     title XIX of such Act, or
       ``(C) entitled to benefits under chapter 55 of title 10, 
     United States Code, including under the TRICARE program (as 
     defined in section 1072(7) of such title).
       ``(3) Identification requirements.--The term `eligible 
     individual' shall not include any individual for any month 
     unless the policy number associated with the qualified health 
     insurance and the TIN of each eligible individual covered 
     under such health insurance for such month are included on 
     the return of tax for the taxable year in which such month 
     occurs.
       ``(4) Prisoners.--The term `eligible individual' shall not 
     include any individual for a month if, as of the first day of 
     such month, such individual is imprisoned under Federal, 
     State, or local authority.
       ``(5) Aliens.--The term `eligible individual' shall not 
     include any alien individual who is not a lawful permanent 
     resident of the United States.
       ``(f) Health Insurance.--For purposes of this section--
       ``(1) Qualified health insurance.--The term `qualified 
     health insurance' means any insurance constituting medical 
     care which (as determined under regulations prescribed by the 
     Secretary)--
       ``(A) has a reasonable annual and lifetime benefit maximum, 
     and
       ``(B) provides coverage for inpatient and outpatient care, 
     emergency benefits, and physician care.
     Such term does not include any insurance substantially all of 
     the coverage of which is coverage described in section 
     223(c)(1)(B).
       ``(2) Qualified refund eligible health insurance.--The term 
     `qualified refund eligible health insurance' means any 
     qualified health insurance which is coverage under a group 
     health plan (as defined in section 5000(b)(1)).
       ``(g) Designated Accounts.--
       ``(1) Designated account.--For purposes of this section, 
     the term `designated account' means any specified account 
     established and maintained by the provider of the taxpayer's 
     qualified refund eligible health insurance--
       ``(A) which is designated by the taxpayer (in such form and 
     manner as the Secretary may provide) on the return of tax for 
     the taxable year,
       ``(B) which, under the terms of the account, accepts the 
     payment described in subsection (d) on behalf of the 
     taxpayer, and
       ``(C) which, under such terms, provides for the payment of 
     expenses by the taxpayer or on behalf of such taxpayer by the 
     trustee or custodian of such account, including payment to 
     such provider.
       ``(2) Specified account.--For purposes of this paragraph, 
     the term `specified account' means--
       ``(A) any health savings account under section 223 or 
     Archer MSA under section 220, or
       ``(B) any health insurance reserve account.
       ``(3) Health insurance reserve account.--For purposes of 
     this subsection, the term `health insurance reserve account' 
     means a trust created or organized in the United States as a 
     health insurance reserve account exclusively for the purpose 
     of paying the qualified medical expenses (within the meaning 
     of section 223(d)(2)) of the account beneficiary (as defined 
     in section 223(d)(3)), but only if the written governing 
     instrument creating the trust meets the requirements 
     described in subparagraphs (B), (C), (D), and (E) of section 
     223(d)(1). Rules similar to the rules under subsections (g) 
     and (h) of section 408 shall apply for purposes of this 
     subparagraph.
       ``(4) Treatment of payment.--Any payment under subsection 
     (d) to a designated account shall not be taken into account 
     with respect to any dollar limitation which applies with 
     respect to contributions to such account (or to tax benefits 
     with respect to such contributions).
       ``(h) Other Definitions.--For purposes of this section--
       ``(1) Dependent.--The term `dependent' has the meaning 
     given such term by section 152 (determined without regard to 
     subsections (b)(1), (b)(2), and (d)(1)(B) thereof). An 
     individual who is a child to whom section 152(e) applies 
     shall be treated as a dependent of the custodial parent for a 
     coverage month unless the custodial and noncustodial parent 
     provide otherwise.
       ``(2) Adult.--The term `adult' means an individual who is 
     not a child.
       ``(3) Child.--The term `child' means a qualifying child (as 
     defined in section 152(c)).
       ``(i) Special Rules.--
       ``(1) Coordination with medical deduction.--Any amount paid 
     by a taxpayer for insurance which is taken into account for 
     purposes of determining the credit allowable to the taxpayer 
     under subsection (a) shall not be taken into account in 
     computing the amount allowable to the taxpayer as a deduction 
     under section 213(a) or 162(l).
       ``(2) Coordination with health care tax credit.--No credit 
     shall be allowed under subsection (a) for any taxable year to 
     any taxpayer and qualifying family members with respect to 
     whom a credit under section 35 is allowed for such taxable 
     year.
       ``(3) Denial of credit to dependents.--No credit shall be 
     allowed under this section to any individual with respect to 
     whom a deduction under section 151 is allowable to another 
     taxpayer for a taxable year beginning in the calendar year in 
     which such individual's taxable year begins.
       ``(4) Married couples must file joint return.--
       ``(A) In general.--If the taxpayer is married at the close 
     of the taxable year, the credit shall be allowed under 
     subsection (a) only if the taxpayer and his spouse file a 
     joint return for the taxable year.
       ``(B) Marital status; certain married individuals living 
     apart.--Rules similar to the rules of paragraphs (3) and (4) 
     of section 21(e) shall apply for purposes of this paragraph.
       ``(5) Verification of coverage, etc.--No credit shall be 
     allowed under this section with respect to any individual 
     unless such individual's coverage (and such related 
     information as the Secretary may require) is verified in such 
     manner as the Secretary may prescribe.
       ``(6) Insurance which covers other individuals; treatment 
     of payments.--Rules similar to the rules of paragraphs (7) 
     and (8) of section 35(g) shall apply for purposes of this 
     section.
       ``(j) Coordination With Advance Payments.--
       ``(1) Reduction in credit for advance payments.--With 
     respect to any taxable year, the amount which would (but for 
     this subsection) be allowed as a credit to the taxpayer under 
     subsection (a) shall be reduced (but not below zero) by the 
     aggregate amount paid on behalf of such taxpayer under 
     section 7527A for months beginning in such taxable year.
       ``(2) Recapture of excess advance payments.--If the 
     aggregate amount paid on behalf of the taxpayer under section 
     7527A for months beginning in the taxable year exceeds the 
     sum of the monthly limitations determined under subsection 
     (b) for the taxpayer and the taxpayer's spouse and dependents 
     for such months, then the tax imposed by this chapter for 
     such taxable year shall be increased by the sum of--
       ``(A) such excess, plus
       ``(B) interest on such excess determined at the 
     underpayment rate established under section 6621 for the 
     period from the date of the payment under section 7527A to 
     the date such excess is paid.
     For purposes of subparagraph (B), an equal part of the 
     aggregate amount of the excess shall be deemed to be 
     attributable to payments made under section 7527A on the 
     first day of each month beginning in such taxable year, 
     unless the taxpayer establishes the date on which each such 
     payment giving rise to such excess occurred, in which case 
     subparagraph (B) shall be applied with respect to each date 
     so established. The Secretary may rescind or waive all or any 
     portion of any amount imposed by reason of subparagraph (B) 
     if such excess was not the result of the actions of the 
     taxpayer.''.
       (b) Advance Payment of Credit.--Chapter 77 (relating to 
     miscellaneous provisions) is amended by inserting after 
     section 7527 the following new section:

     ``SEC. 7527A. ADVANCE PAYMENT OF CREDIT FOR QUALIFIED REFUND 
                   ELIGIBLE HEALTH INSURANCE.

       ``(a) In General.--The Secretary shall establish a program 
     for making payments on behalf of individuals to providers of 
     qualified refund eligible health insurance (as defined in 
     section 25E(f)(2)) for such individuals.
       ``(b) Limitation.--The Secretary may make payments under 
     subsection (a) only to the extent that the Secretary 
     determines that the amount of such payments made on behalf of 
     any taxpayer for any month does not exceed the sum of the 
     monthly limitations determined under section 25E(b) for the 
     taxpayer and taxpayer's spouse and dependents for such 
     month.''.
       (c) Information Reporting.--
       (1) In general.--Subpart B of part III of subchapter A of 
     chapter 61 (relating to information concerning transactions 
     with other persons) is amended by inserting after section 
     6050W the following new section:

     ``SEC. 6050X. RETURNS RELATING TO CREDIT FOR QUALIFIED REFUND 
                   ELIGIBLE HEALTH INSURANCE.

       ``(a) Requirement of Reporting.--Every person who is 
     entitled to receive payments for any month of any calendar 
     year under section 7527A (relating to advance payment of 
     credit for qualified refund eligible health insurance) with 
     respect to any individual shall, at such time as the 
     Secretary may prescribe, make the return described in 
     subsection (b) with respect to each such individual.

[[Page 32797]]

       ``(b) Form and Manner of Returns.--A return is described in 
     this subsection if such return--
       ``(1) is in such form as the Secretary may prescribe, and
       ``(2) contains, with respect to each individual referred to 
     in subsection (a)--
       ``(A) the name, address, and TIN of each such individual,
       ``(B) the months for which amounts payments under section 
     7527A were received,
       ``(C) the amount of each such payment,
       ``(D) the type of insurance coverage provided by such 
     person with respect to such individual and the policy number 
     associated with such coverage,
       ``(E) the name, address, and TIN of the spouse and each 
     dependent covered under such coverage, and
       ``(F) such other information as the Secretary may 
     prescribe.
       ``(c) Statements To Be Furnished to Individuals With 
     Respect to Whom Information Is Required.--Every person 
     required to make a return under subsection (a) shall furnish 
     to each individual whose name is required to be set forth in 
     such return a written statement showing--
       ``(1) the contact information of the person required to 
     make such return, and
       ``(2) the information required to be shown on the return 
     with respect to such individual.
     The written statement required under the preceding sentence 
     shall be furnished on or before January 31 of the year 
     following the calendar year for which the return under 
     subsection (a) is required to be made.
       ``(d) Returns Which Would Be Required To Be Made by 2 or 
     More Persons.--Except to the extent provided in regulations 
     prescribed by the Secretary, in the case of any amount 
     received by any person on behalf of another person, only the 
     person first receiving such amount shall be required to make 
     the return under subsection (a).''.
       (2) Assessable penalties.--
       (A) Subparagraph (B) of section 6724(d)(1) (relating to 
     definitions) is amended by striking ``or'' at the end of 
     clause (xxii), by striking ``and'' at the end of clause 
     (xxiii) and inserting ``or'', and by inserting after clause 
     (xxiii) the following new clause:
       ``(xxiv) section 6050X (relating to returns relating to 
     credit for qualified refund eligible health insurance), 
     and''.
       (B) Paragraph (2) of section 6724(d) is amended by striking 
     ``or'' at the end of subparagraph (EE), by striking the 
     period at the end of subparagraph (FF) and inserting ``, or'' 
     and by inserting after subparagraph (FF) the following new 
     subparagraph:
       ``(GG) section 6050X (relating to returns relating to 
     credit for qualified refund eligible health insurance).''.
       (d) Conforming Amendments.--
       (1) Paragraph (2) of section 1324(b) of title 31, United 
     States Code, is amended by inserting ``25E,'' before ``35,''.
       (2)(A) Section 24(b)(3)(B) is amended by inserting ``, 
     25E,'' after ``25D''.
       (B) Section 25(e)(1)(C)(ii) is amended by inserting 
     ``25E,'' after ``25D,''.
       (C) Section 25B(g)(2) is amended by inserting ``25E,'' 
     after ``25D,''.
       (D) Section 26(a)(1) is amended by inserting ``25E,'' after 
     ``25D,''.
       (E) Section 30(c)(2)(B)(ii) is amended by inserting 
     ``25E,'' after ``25D,''.
       (F) Section 30D(c)(2)(B)(ii) is amended by striking ``and 
     25D'' and inserting ``, 25D, and 25E''.
       (G) Section 904(i) is amended by inserting ``25E,'' after 
     ``25B,''.
       (H) Section 1400C(d)(2) is amended by inserting ``25E,'' 
     after ``25D,''.
       (3) The table of sections for subpart A of part IV of 
     subchapter A of chapter 1 is amended by inserting after the 
     item relating to section 25D the following new item:

``Sec. 25E. Qualified health insurance credit.''.
       (4) The table of sections for chapter 77 is amended by 
     inserting after the item relating to section 7527 the 
     following new item:

``Sec. 7527A. Advance payment of credit for qualified refund eligible 
              health insurance.''.
       (5) The table of sections for subpart B of part III of 
     subchapter A of chapter 61 is amended by adding at the end 
     the following new item:

``Sec. 6050X. Returns relating to credit for qualified refund eligible 
              health insurance.''.
       (e) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2010.

     SEC. 302. REQUIRING EMPLOYER TRANSPARENCY ABOUT EMPLOYEE 
                   BENEFITS.

       (a) In General.--Section 6051(a) (relating to W-2 
     requirement) is amended by striking ``and'' at the end of 
     paragraph (12), by striking the period at the end of 
     paragraph (13) and inserting ``, and'' and by inserting after 
     paragraph (13) the following new paragraph:
       ``(14) the aggregate cost (within the meaning of section 
     4980B(f)(4)) for coverage of the employee under an accident 
     or health plan which is excludable from the gross income of 
     the employee under section 106(a) (other than coverage under 
     a health flexible spending arrangement).''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to statements for calendar years beginning after 
     2009.

     SEC. 303. CHANGES TO EXISTING TAX PREFERENCES FOR MEDICAL 
                   COVERAGE, ETC., FOR INDIVIDUALS ELIGIBLE FOR 
                   QUALIFIED HEALTH INSURANCE CREDIT.

       (a) Exclusion for Contributions by Employer to Accident and 
     Health Plans.--
       (1) In general.--Section 106 (relating to contributions by 
     employer to accident and health plans) is amended by adding 
     at the end the following new subsection:
       ``(f) No Exclusion for Individuals Eligible for Qualified 
     Health Insurance Credit.--Subsection (a) shall not apply with 
     respect to any employer-provided coverage under an accident 
     or health plan for any individual for any month unless such 
     individual is described in paragraph (2) or (5) of section 
     25E(e) for such month. The amount includible in gross income 
     by reason of this subsection shall be determined under rules 
     similar to the rules of section 4980B(f)(4).''.
       (2) Conforming amendments.--
       (A) Section 106(b)(1) is amended--
       (i) by inserting ``gross income does not include'' before 
     ``amounts contributed'', and
       (ii) by striking ``shall be treated as employer-provided 
     coverage for medical expenses under an accident or health 
     plan''.
       (B) Section 106(d)(1) is amended--
       (i) by inserting ``gross income does not include'' before 
     ``amounts contributed'', and
       (ii) by striking ``shall be treated as employer-provided 
     coverage for medical expenses under an accident or health 
     plan''.
       (b) Amounts Received Under Accident and Health Plans.--
     Section 105 (relating to amounts received under accident and 
     health plans) is amended by adding at the end the following 
     new subsection:
       ``(f) No Exclusion for Individuals Eligible for Qualified 
     Health Insurance Credit.--Subsection (b) shall not apply with 
     respect to any employer-provided coverage under an accident 
     or health plan for any individual for any month unless such 
     individual is described in paragraph (2) or (5) of section 
     25E(e) for such month.''.
       (c) Special Rules for Health Insurance Costs of Self-
     Employed Individuals.--Subsection (l) of section 162 
     (relating to special rules for health insurance costs of 
     self-employed individuals) is amended by adding at the end 
     the following new paragraph:
       ``(6) No deduction to individuals eligible for qualified 
     health insurance.--Paragraph (1) shall not apply for any 
     individual for any month unless such individual is described 
     in paragraph (2) or (5) of section 25E(e) for such month.''.
       (d) Earned Income Credit Unaffected by Repealed 
     Exclusions.--Subparagraph (B) of section 32(c)(2) is amended 
     by redesignating clauses (v) and (vi) as clauses (vi) and 
     (vii), respectively, and by inserting after clause (iv) the 
     following new clause:
       ``(v) the earned income of an individual shall be computed 
     without regard to sections 105(f) and 106(f),''.
       (e) Modification of Deduction for Medical Expenses.--
     Subsection (d) of section 213 is amended by adding at the end 
     the following new paragraph:
       ``(12) Premiums for qualified health insurance.--The term 
     `medical care' does not include any amount paid as a premium 
     for coverage of an eligible individual (as defined in section 
     25E(e)) under qualified health insurance (as defined in 
     section 25E(f)) for any month.''.
       (f) Reporting Requirement.--Subsection (a) of section 6051 
     is amended by striking ``and'' at the end of paragraph (12), 
     by striking the period at the end of paragraph (13) and 
     inserting ``and'', and by inserting after paragraph (13) the 
     following new paragraph:
       ``(14) the total amount of employer-provided coverage under 
     an accident or health plan which is includible in gross 
     income by reason of sections 105(f) and 106(f).''.
       (g) Retired Public Safety Officers.--Section 402(l)(4)(D) 
     is amended by adding at the end the following: ``Such term 
     shall not include any premium for coverage by an accident or 
     health insurance plan for any month unless such individual is 
     described in paragraph (2) or (5) of section 25E(e) for such 
     month.''.
       (h) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2010.
       (i) No Intent To Encourage State Taxation of Health 
     Benefits.--No intent to encourage any State to treat health 
     benefits as taxable income for the purpose of increasing 
     State income taxes may be inferred from the provisions of, 
     and amendments made by, this section.

     SEC. 304. DETERMINATION OF ELIGIBILITY.

       (a) Application of Income and Eligibility Verification 
     System (IEVS) and the Systematic Alien Verification for 
     Entitlements (SAVE) Programs.--In order to obtain coverage 
     through an Exchange, an individual must have had his or her 
     eligibility determined and approved under the Income and 
     Eligibility Verification System (IEVS) and the Systematic 
     Alien Verification for Entitlements (SAVE) programs under 
     section 1137 of the Social Security Act. The benefit 
     determination and approval under this subsection shall be the 
     responsibility of the Exchange-participating health plans 
     involved.
       (b) Credits.--In addition to satisfying the eligibility 
     requirements specified in subsection (a), to be considered a 
     credit eligible

[[Page 32798]]

     individual under the amendments made by this title, an 
     individual must have had his or her eligibility for the 
     credit determined and approved under the Income and 
     Eligibility Verification System (IEVS) and the Systematic 
     Alien Verification for Entitlements (SAVE) programs under 
     section 1137 of the Social Security Act. The benefit 
     determination and approval under this subsection shall be the 
     responsibility of the Exchange-participating health plans in 
     which the individual enrolls and attempts to utilize the 
     credit.
       (c) Effective Date.--The amendment made by this section 
     shall apply to taxable years beginning after December 31, 
     2009.

     SEC. 305. ADJUSTMENTS.

       Notwithstanding any other provision of law, the Secretary 
     of the Treasury shall adjust the growth of tax credits 
     provided for under this amendments made by this title at such 
     levels as appropriate so that this Act will remain budget 
     neutral.

             TITLE IV--FAIRNESS FOR EVERY AMERICAN PATIENT

                   Subtitle A--Medicaid Modernization

     SEC. 401. MEDICAID MODERNIZATION.

       (a) In General.--Effective January 1, 2011, title XIX of 
     the Social Security Act (42 U.S.C. 1396 et seq.) is amended 
     to read as follows:

     ``TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

                      ``TABLE OF CONTENTS OF TITLE

``Sec. 1900. References to pre-modernized Medicaid provisions; 
              continuity for commonwealths and territories.

    ``Part A--Grants to States for Acute Care for Individuals With 
            Disabilities and Certain Low-Income Individuals

``Sec. 1901. Purpose; Appropriation.
``Sec. 1902. Payments to States for acute care medical assistance.
``Sec. 1903. Definitions of eligible individuals and acute care medical 
              assistance.
``Sec. 1904. State plan requirements for acute care medical assistance.
``Sec. 1905. Definitions.
``Sec. 1906. Enrollment of individuals under group health plans and 
              other arrangements.
``Sec. 1907. Drug rebates.
``Sec. 1908. Managed care.
``Sec. 1909. Annual reports.

  ``Part B--Grants to States for Long-Term Care Services and Supports

``Sec. 1911. Purpose.
``Sec. 1912. State plan.
``Sec. 1913. State allotments.
``Sec. 1914. Use of grants.
``Sec. 1915. Administrative provisions.
``Sec. 1916. Definition of long-term care services and supports.
``Sec. 1917. Provision requirements for long-term care services and 
              supports, including option for self-directed services and 
              supports.
``Sec. 1918. Treatment of income and resources for certain 
              institutionalized spouses.
``Sec. 1919. Annual reports.

  ``Part C--Grants to States for Survey and Certification of Medical 
                   Facilities and Other Requirements

``Sec. 1931. Authorization of appropriations.
``Sec. 1932. Application of certain requirements under pre-modernized 
              Medicaid.

            ``Part D--Grants to States for Program Integrity

``Sec. 1941. Authorization of appropriations.
``Sec. 1942. Application of certain requirements under pre-modernized 
              Medicaid.

             ``Part E--Grants to States for Administration

``Sec. 1951. Authorization of appropriations; payments to states.
``Sec. 1952. Cost-sharing protections.
``Sec. 1953. Application of certain requirements under pre-modernized 
              Medicaid.

                       ``Part F--Other Provisions

``Sec. 1961. Application of certain requirements under pre-modernized 
              Medicaid.

     ``SEC. 1900. REFERENCES TO PRE-MODERNIZED MEDICAID 
                   PROVISIONS; CONTINUITY FOR COMMONWEALTHS AND 
                   TERRITORIES.

       ``(a) In General.--In this title, if a reference to this 
     title or to a provision of this title is prefaced by the term 
     `old', such reference is to this title or a provision of this 
     title as in effect on December 31, 2010.
       ``(b) Regulations.--The Secretary shall promulgate 
     regulations to bring requirements imposed under an old 
     provision of this title that applies under this title after 
     December 31, 2010, into conformity with the policies embodied 
     in this title as in effect on and after January 1, 2011.
       ``(c) Continuity for Commonwealths and Territories.--In the 
     case of Puerto Rico, the United States Virgin Islands, Guam, 
     the Northen Mariana Islands, and American Samoa, this title 
     as in effect on and after January 1, 2011, shall not apply to 
     such commonwealths and territories, and old title XIX shall 
     apply to a Medicaid program operated by such commonwealths or 
     territories on and after that date.

    ``PART A--GRANTS TO STATES FOR ACUTE CARE FOR INDIVIDUALS WITH 
            DISABILITIES AND CERTAIN LOW-INCOME INDIVIDUALS

     ``SEC. 1901. PURPOSE; APPROPRIATION.

       ``(a) Purpose.--It is the purpose of this part to enable 
     each State, as far as practicable under the conditions in the 
     State, to provide acute care medical assistance to eligible 
     individuals described in section 1903 whose income and 
     resources are insufficient to meet the costs of necessary 
     medical services, and (2) rehabilitation and other services 
     to help such individuals attain or retain capability for 
     independence or self-care.
       ``(b) Appropriation.--For the purpose of making payments to 
     States under this part, there is appropriated out of any 
     money in the Treasury not otherwise appropriated, such sums 
     as are necessary for fiscal year 2011 and each fiscal year 
     thereafter.

     ``SEC. 1902. PAYMENTS TO STATES FOR ACUTE CARE MEDICAL 
                   ASSISTANCE.

       ``(a) In General.--From the amounts appropriated under 
     section 1901 for a fiscal year, the Secretary shall pay to 
     each State which has a plan approved under this part, for 
     each quarter, beginning with the quarter commencing January 
     1, 2011, an amount equal to the Federal medical assistance 
     percentage (as defined in section 1905(b)) of the total 
     amount expended during such quarter as acute care medical 
     assistance under the State plan under this part.
       ``(b) Administrative Expenses.--Each State with a plan 
     approved under this part shall receive a payment determined 
     in accordance with part E for administrative expenses 
     incurred in carrying out the plan under this part and part B 
     (if the State has a plan approved under that part).

     ``SEC. 1903. DEFINITIONS OF ELIGIBLE INDIVIDUALS AND ACUTE 
                   CARE MEDICAL ASSISTANCE.

       ``(a) Eligible Individuals.--
       ``(1) In general.--In this part, the term `eligible 
     individual' means an individual--
       ``(A) who is--
       ``(i) a blind or disabled individual; or
       ``(ii) an individual described in paragraph (2); and
       ``(B) who the State determines satisfies--
       ``(i) the income and resources eligibility requirements 
     established by the State under the State plan under this 
     part; and
       ``(ii) such other requirements for assistance as are 
     imposed under this title, including documentation of 
     citizenship or status as a qualified alien under title IV of 
     the Personal Responsibility and Work Opportunity 
     Reconciliation Act of 1996.
       ``(2) Individuals described.--For purposes of paragraph 
     (1)(A)(ii), the following individuals are described in this 
     paragraph:
       ``(A) A child in foster care under the responsibility of 
     the State.
       ``(B) A low-income woman with breast or cervical cancer 
     described in old section 1902(aa).
       ``(C) Certain TB-infected individuals described in old 
     section 1902(z)(1).
       ``(3) Grandfathered individuals.--An individual shall be an 
     eligible individual under the State plan under this part if--
       ``(A) the individual is described in paragraph (1)(A);
       ``(B) the individual satisfies the documentation 
     requirements referred to in paragraph (1)(B)(ii); and
       ``(C) the State would have provided medical assistance 
     under the State plan under old title XIX to the individual, 
     but only so long as the individual continues to satisfy such 
     old eligibility requirements.
       ``(4) Concurrent eligibility for part b.--An eligible 
     individual under this part may be eligible under part B, but 
     only if the individual satisfies the eligibility requirements 
     of part B in addition to satisfying the requirements for 
     eligibility under this part.
       ``(5) Presumptive eligibility for certain breast or 
     cervical cancer patients.--Old section 1920B (relating to 
     presumptive eligibility for certain breast or cervical cancer 
     patients) shall apply under this part.
       ``(b) Benefits.--Subject to paragraph (3), in this part, 
     the term `acute care medical assistance' means the following:
       ``(1) Mandatory benefits.--The care and services listed in 
     paragraphs (1) through (5), (17), and (21) of old section 
     1905(a) (but, in the case of paragraph (4)(A) of such 
     section, without regard to any limitation based on age or 
     services in an institution for mental diseases).
       ``(2) Optional benefits.--Any care or services listed in a 
     paragraph of old section 1905(a) (other than paragraph (16)).
       ``(3) Exceptions.--
       ``(A) Certain services limited to part b.--Services 
     described in paragraphs (15), (22), (23), (24), and (26) of 
     old section 1905(a) shall only be provided under the State 
     plan under part B.
       ``(B) Limit on provision of long-term care services and 
     supports.--A care or service that the Secretary determines is 
     a long-term care service and support (including nursing 
     facility services described in old section 1905(a)(4)(A)) 
     shall not be provided to an individual under the State plan 
     under this part for more than 30 days within any 12-month 
     period.
       ``(C) Exclusions.--Such term shall not include any payments 
     with respect to care or services for any individual who is an 
     inmate

[[Page 32799]]

     of a public institution or a patient in an institution for 
     mental diseases (regardless of age).

     ``SEC. 1904. STATE PLAN REQUIREMENTS FOR ACUTE CARE MEDICAL 
                   ASSISTANCE.

       ``(a) In General.--In order to receive payments under this 
     part, a State shall have an approved State plan for acute 
     care medical assistance. For purposes of this part, such 
     assistance includes payments for preventive care, primary 
     care, diagnosis and treatment of acute and chronic health 
     conditions, emergency care, diagnosis and treatment of mental 
     illnesses and related conditions, and rehabilitation and 
     other services to help eligible individuals attain or retain 
     capability for independence or self-care. A State medical 
     assistance plan shall include a description, consistent with 
     the requirements of this part of--
       ``(1) eligibility standards, including income and asset 
     standards;
       ``(2) benefits, including the amount, duration, and scope 
     of covered items and services;
       ``(3) strategies for improving access and quality of care; 
     and
       ``(4) methods of service delivery.
       ``(b) Public Availability of State Plan.--The State shall 
     make available to the public the State plan under this part 
     and any amendments submitted by the State to the plan.
       ``(c) Amount, Duration, and Scope.--The State plan shall 
     provide that the acute care medical assistance made available 
     to any eligible individual shall not be less in amount, 
     duration, or scope than the acute care medical assistance 
     made available to any other eligible individual.
       ``(d) Application of Certain Pre-Modernized Medicaid 
     Requirements.--
       ``(1) Old state plan requirements.--The following 
     provisions of old section 1902 shall apply to the State plans 
     under this part:
       ``(A) Old section 1902(a)(10)(C) (relating to certain 
     eligibility and other requirements).
       ``(B) Old section 1902(a)(10)(D) (relating to home health 
     services).
       ``(C) Old section 1902(a)(10)(G) (relating to 
     nonapplication of certain supplemental security income 
     eligibility criteria).
       ``(D) The subclauses in the flush matter following old 
     section 1902(a)(10)(G) (relating to the provision of certain 
     services) other than subclauses (V), (VII), (VIII), and (IX).
       ``(E) Old section 1902(a)(17) (relating to reasonable 
     standards for determining eligibility).
       ``(F) Old section 1902(a)(19) (relating to eligibility 
     safeguards).
       ``(G) Old section 1902(a)(34) (relating to eligibility 
     beginning with the third month prior to the month of 
     application).
       ``(H) Subparagraphs (A), (B), and (C) of old section 
     1902(a)(43) (relating to early and periodic screening, 
     diagnostic, and treatment services).
       ``(I) Old section 1902(a)(46)(A) (relating to compliance 
     with section 1137 requirements).
       ``(J) The fourth and sixth sentences of old section 1902(a) 
     (relating to eligibility for certain individuals).
       ``(2) Other old title xix requirements.--
       ``(A) Old section 1902(e)(3) (relating to optional 
     eligibility for certain disabled individuals).
       ``(B) Old section 1902(e)(9) (relating to optional 
     respiratory care services).
       ``(C) Old section 1902(f) (relating to eligibility of 
     certain aged, blind, or disabled individuals).
       ``(D) Old section 1902(m) (relating to eligibility of 
     certain aged or disabled individuals), other than paragraph 
     (4).
       ``(E) Old section 1902(o) (relating to disregard of certain 
     supplemental security income benefits).
       ``(F) Old section 1902(v) (relating to eligibility 
     determinations of blind or disabled individuals).
       ``(e) Other Requirements.--The State plan under this part 
     shall--
       ``(1) comply with the requirements of the other parts of 
     this title; and
       ``(2) provide that the State will make the contributions 
     specified under section 340A-1(e) of the Public Health 
     Service Act .

     ``SEC. 1905. DEFINITIONS.

       ``(a) In General.--The definitions specified in this 
     section shall apply for purposes of this part and, to the 
     extent applicable and consistent with the policy embodied in 
     such part, parts B, C, D, E, and F.
       ``(b) Federal Medical Assistance Percentage.--The term 
     `Federal medical assistance percentage' for any State shall 
     be 100 percent less the State percentage; and the State 
     percentage shall be that percentage which bears the same 
     ratio to 45 percent as the square of the per capita income of 
     such State bears to the square of the per capita income of 
     the continental United States (including Alaska) and Hawaii, 
     except that the Federal medical assistance percentage shall 
     in no case be less than 50 percent or more than 83 percent. 
     The Federal medical assistance percentage for any State shall 
     be determined and promulgated in accordance with the 
     provisions of section 1101(a)(8)(B).
       ``(c) Application of Certain Pre-Modernized Medicaid 
     Provisions.--The following old provisions shall apply under 
     this part:
       ``(1) Old section 1905 provisions.--The following 
     provisions of old section 1905:
       ``(A) Old section 1905(d) (relating to the definition of an 
     intermediate care facility for the mentally retarded).
       ``(B) Old section 1905(e) (relating to the definition of 
     physicians services).
       ``(C) Old section 1905(f) (relating to the definition of 
     nursing facility services).
       ``(D) Old section 1905(g) (relating to the provision of 
     chiropractors' services).
       ``(E) Old section 1905(j) (relating to State supplementary 
     payments).
       ``(F) Old section 1905(k) (relating to supplemental 
     security income benefits payable pursuant to section 211 of 
     Public Law 93-66).
       ``(G) Old section 1905(l)(1) (relating to rural health 
     clinic services).
       ``(H) Old section 1905(o) (relating to hospice care).
       ``(I) Old section 1905(q) (relating to the definition of a 
     qualified severely impaired individual).
       ``(J) Old section 1905(r) (relating to the definition of 
     early and periodic screening, diagnostic, and treatment 
     services).
       ``(K) Old section 1905(s) (relating to the definition of a 
     qualified disabled and working individual).
       ``(L) Old section 1905(t) (relating to the definition of 
     primary care case management services).
       ``(M) Old section 1905(v) (relating to the definition of an 
     employed individual with a medically improved disability).
       ``(N) Paragraphs (1) and (3) of old section 1905(w) 
     (relating to the definition of an independent foster care 
     adolescent).
       ``(O) Old section 1905(x) (relating to strategies, 
     treatment, and services for individuals with Sickle Cell 
     Disease).
       ``(2) Other old provisions.--
       ``(A) Old section 1903(m) (relating to the definition of a 
     medicaid managed care organization).

     ``SEC. 1906. ENROLLMENT OF INDIVIDUALS UNDER GROUP HEALTH 
                   PLANS AND OTHER ARRANGEMENTS.

       ``The following old provisions shall apply under this part:
       ``(1) Old section 1906 (relating to enrollment of 
     individuals under group health plans).
       ``(2) Old section 1902(a)(70) (relating to State option to 
     establish a non-emergency medical transportation brokerage 
     program).
       ``(3) Paragraphs (2) and (11) of old section 1902(e) 
     (relating to eligibility for individuals enrolled with a 
     group health plan or under a managed care arrangement during 
     a minimum enrollment period).

     ``SEC. 1907. DRUG REBATES.

       ``Old sections 1902(a)(54) and 1927 (relating to payment 
     for covered outpatient drugs and rebates) shall apply under 
     this part.

     ``SEC. 1908. MANAGED CARE.

       ``The following old provisions shall apply under this part:
       ``(1) Old section 1932 (relating to managed care), other 
     than subsection (a)(2) of such section.
       ``(2) Old section 1903(k) (relating to technical and 
     actuarial assistance for States).

     ``SEC. 1909. ANNUAL REPORTS.

       ``(a) In General.--Each State that receives payments under 
     this part shall submit an annual report to the Secretary, in 
     such form and manner as the Secretary shall specify.
       ``(b) Application of Old EPSDT Reporting Requirements.--
     Each annual report shall include the information required to 
     be reported under old section 1902(a)(43)(D)(iv).

  ``PART B--GRANTS TO STATES FOR LONG-TERM CARE SERVICES AND SUPPORTS

     ``SEC. 1911. PURPOSE.

       ``(a) In General.--The purpose of this part is to increase 
     the flexibility of States in operating a system of long-term 
     care services and supports designed to--
       ``(1) provide assistance to needy families so that 
     individuals with disabilities and low-income senior citizens 
     may be served and supported in their own homes and 
     communities;
       ``(2) emphasize the independence and dignity of the person 
     served by public programs;
       ``(3) end the institutional bias that existed under the 
     Medicaid program prior to January 1, 2011;
       ``(4) provide stable and predictable funding for States as 
     they rebalance their long-term care systems from institutions 
     to communities;
       ``(5) provide flexibility to States to adopt new and 
     innovative service delivery methods; and
       ``(6) promote independence and support activities that will 
     enable individuals to return or maintain ties to the 
     community, including through employment.
       ``(b) No Individual Entitlement.--No individual determined 
     eligible for long-term care services and supports under this 
     part shall be entitled to a specific service or type of 
     delivery of service.

     ``SEC. 1912. STATE PLAN.

       ``(a) In General.--In order to receive payments under this 
     part, a State must have an approved State plan for long-term 
     care services and supports. A State long term care services 
     and supports plan shall include a description, consistent 
     with the requirements of this part, of--
       ``(1) income and assets eligibility standards and spousal 
     impoverishment protections consistent with subsection (b);
       ``(2) the standardized assessments tools used to determine 
     eligibility for specific long-term care services and 
     supports;

[[Page 32800]]

       ``(3) the person-centered plans used to provide such 
     services and supports;
       ``(4) the proposed uses of funding, if applicable, to 
     provide targeted methods to meet individual level of support 
     needs including tiering (preventive, emergency, low, medium, 
     high); and
       ``(5) the long-term care services and supports to be 
     available under the plan based on individual assessment of 
     need in accordance with sections 1916 and 1917.
       ``(b) Minimum Eligibility Standards.--
       ``(1) Populations covered.--The State plan shall specify 
     the disabled and elderly populations who are eligible for 
     long-term care services and supports.
       ``(2) Needs-based criteria.--The plan shall include a 
     description of the needs-based criteria the State will use to 
     assess an individual's need for specific services and 
     supports available under the State plan.
       ``(3) Other eligibility requirements.--
       ``(A) Income and assets.--A State may use different income 
     and asset standards and methodologies for determining 
     eligibility than those used for determining eligibility for 
     acute care medical assistance under part A. A State may not 
     make eligibility standards related to income, asset, and 
     spousal impoverishment protection more restrictive than the 
     Federal minimum requirements of December 31, 2008.
       ``(B) Application of spousal impoverishment protections.--
     The State plan shall provide that the State shall comply with 
     the requirements of section 1918 (relating to spousal 
     impoverishment protections).
       ``(C) Statewideness.--The State plan shall provide that, 
     except with respect to methods used for determining homestead 
     exemptions, the income and asset standards and methodologies 
     shall be in effect in all political subdivisions of the 
     State.
       ``(4) Transition assistance.--The State plan shall specify 
     how the State will provide transition assistance for 
     individuals who, on December 31, 2010, are enrolled under the 
     State plan under old title XIX (or under a waiver of that 
     plan) and receiving long-term care services or supports on 
     that date. The State shall provide such assistance to 
     individuals who are and are not likely to be determined 
     eligible for long-term care services and supports under the 
     State plan under this part, as in effect on January 1, 2011 
     (or the first day on which the State plan is in effect under 
     this part).
       ``(c) Payment Methodologies to Providers.--
       ``(1) In general.--The State plan shall describe the 
     methodologies used to determine payments to providers. Such 
     methodologies--
       ``(A) may be varied to assist in transitioning from 
     facilities-based to community-based care; and
       ``(B) shall not be subject to Secretarial approval.
       ``(2) Transparency.--The State plan shall provide that the 
     State shall make publicly available--
       ``(A) the payment methodologies applicable under the plan; 
     and
       ``(B) the name of any provider that receives $1,000,000 or 
     more in any 12-month period and the actual amount paid to the 
     provider during that period.
       ``(d) Coordination of Effort With Other Related Public and 
     Private Programs.--The plan shall include a description of 
     the State's efforts to coordinate the delivery of services 
     and supports under the plan with other related public and 
     private programs that serve individuals with disabilities or 
     aged populations that need or may be at risk of needing long 
     term care.
       ``(e) Public Availability of State Plan.--The State shall 
     make available to the public the State plan under this part 
     and any amendments submitted by the State to the plan.
       ``(f) Application of Old Title XIX Requirements.--The 
     following old title XIX provisions shall apply to a State 
     plan under this part:
       ``(1) Subsections (a)(50) and (q) of old section 1902 
     (relating to a monthly personal needs allowance for certain 
     institutionalized individuals and couples).
       ``(2) Old section 1902(a)(67) (relating to payment for 
     certain services furnished to a PACE program eligible 
     individual).
       ``(3) Paragraph (1) of old section 1902(r) (relating to the 
     post-eligibility treatment of income for certain individuals) 
     and paragraph (2) of such section (relating to methodologies 
     for determining income and resource eligibility for 
     individuals, but only with respect to individuals who are 
     eligible under this part on or after January 1, 2011).
       ``(4) Old section 1905(i) (relating to the definition of an 
     institution for mental diseases).
       ``(g) Other Requirements of Other Parts.--The State plan 
     under this part shall--
       ``(1) comply with the requirements of the other parts of 
     this title; and
       ``(2) provide that the State will make the contributions 
     specified under section 340A-1(e) of the Public Health 
     Service Act.

     ``SEC. 1913. STATE ALLOTMENTS.

       ``(a) Appropriation.--For the purpose of providing 
     allotments to States under this section, there is 
     appropriated out of any money in the Treasury not otherwise 
     appropriated--
       ``(1) for fiscal year 2011, $65,274,560,000;
       ``(2) for fiscal year 2012, $67,885,540,000;
       ``(3) for fiscal year 2013, $70,600,964,100;
       ``(4) for fiscal year 2014, $73,425,000,000;
       ``(5) for fiscal year 2015, $76,362,000,000;
       ``(6) for fiscal year 2016, $79,416,480,000;
       ``(7) for fiscal year 2017, $82,593,140,000;
       ``(8) for fiscal year 2018, $85,896,870,000; and
       ``(9) for fiscal year 2019, $89,332,743,000.
       ``(b) Allotments to 50 States and the District of 
     Columbia.--
       ``(1) Fiscal year 2011 allotments.--Subject to subsection 
     (e), the Secretary shall allot to each State with a long term 
     care plan approved under this title an amount in fiscal year 
     2011 equal to the Federal expenditures made by the State for 
     long-term care as defined in section 1916 in fiscal year 
     2008, increased by 8 percent.
       ``(2) Subsequent fiscal year allotments.--For fiscal year 
     2012 and each subsequent fiscal year through fiscal year 
     2019, the allotment for a State under this section is equal 
     to the allotment for the State determined for the preceding 
     fiscal year, increased by 4 percent.
       ``(c) Limitation.--
       ``(1) In general.--Except as provided in paragraph (2), no 
     other Federal funds are available under this title for 
     expenditures incurred for long-term care services and 
     supports after December 31, 2010, except as provided under a 
     State plan approved under this part.
       ``(2) Exception.--
       ``(A) In general.--If a State does not have an approved 
     State plan by October 1, 2010, the Secretary may make 
     payments equal to 85 percent of the State's estimated 
     quarterly allotment until June 30, 2011.
       ``(B) Full funding.--A State shall receive 100 percent of 
     its allotment for fiscal year 2011 if the State has a plan 
     approved under this part by June 30, 2011.
       ``(d) Maintenance of Effort.--In order to qualify for the 
     grant payable under this section, the State must demonstrate 
     in each fiscal year that it made long-term care service and 
     supports expenditures (including funding from local 
     government sources) equal to the amount of not less than 95 
     percent of the nonfederal share amount spent in fiscal year 
     2009 under the State plan under old title XIX on long term 
     care services and supports (as defined in section 1916). 
     Expenditures not made under this part shall not be recognized 
     by the Secretary for purposes of this requirement.
       ``(e) Grants Reduced if Insufficient Appropriations.--
       ``(1) In general.--If the amount appropriated for fiscal 
     year 2011 under subsection (a)(1) is less than the amount 
     necessary to fund each State's allotment for that fiscal 
     year, the Secretary shall reduce the allotment for each State 
     for that fiscal year based on the applicable percentage 
     determined for the State under paragraph (2).
       ``(2) Applicable percentage.--For purposes of paragraph 
     (1), the applicable percentage determined with respect to a 
     State is as follows:


 
 
 
``If the ratio of the State's non-       The applicable percentage is:
 institutional spending to total long-
 term care spending for fiscal year
 2009 is:
  50 percent or greater................  100
  at least 46, but less than 50 percent  99
  at least 40, but less than 46 percent  98
  at least 36, but less than 40........  97
  at least 30, but less than 36........  96
  less than 30 percent.................  95.
 


       ``(f) Administrative Expenses.--
       ``(1) In general.--Each State with a plan approved under 
     this part shall receive a payment determined in accordance 
     with amounts appropriated for part E for administrative 
     expenses incurred in carrying out the plan under this part 
     and part A.
       ``(2) Assessment-related costs.--Costs attributable to 
     providing an individualized needs-based assessment for 
     purposes of identifying the long-term care services and 
     supports to be provided under the State plan to an individual 
     shall be considered a long-term care service and support and 
     shall not be treated as an administrative expense.

[[Page 32801]]



     ``SEC. 1914. USE OF GRANTS.

       ``(a) In General.--A State shall use funds for long-term 
     care services and supports as defined in section 1916.
       ``(b) Self-Direction.--A State shall offer individuals the 
     opportunity to self-direct their long-term care services and 
     supports.

     ``SEC. 1915. ADMINISTRATIVE PROVISIONS.

       ``(a) Funding on a Quarterly Basis.--The Secretary shall 
     make payments to States in equal amounts of a State's annual 
     allotment on a quarterly basis. Each quarterly payment shall 
     remain available for use by the State for twelve succeeding 
     fiscal year quarters.
       ``(b) Publication.--The Secretary shall publish each 
     State's allotment--
       ``(1) for fiscal year 2011 not later than December 15, 
     2009; and
       ``(2) for each subsequent fiscal year, not later than 
     December 15 of the calendar year preceding the calendar year 
     in which the fiscal year begins.

     ``SEC. 1916. DEFINITION OF LONG-TERM CARE SERVICES AND 
                   SUPPORTS.

       ``(a) Definition.--
       ``(1) In general.--Subject to subsection (e), in this part, 
     the term `long-term care services and supports' means any of 
     the services or supports specified in paragraphs (2) or (3) 
     that may be provided in a nursing facility, an institution, a 
     home, or other setting.
       ``(2) Services and supports described.--For purposes of 
     paragraph (1), the services and supports described in this 
     paragraph include assistive technology, adaptive equipment, 
     remote monitoring equipment, case management for the aged, 
     case management for individuals with disabilities, nursing 
     home services, long-term rehabilitative services necessary to 
     restore functional abilities, services provided in 
     intermediate care facilities for people with disabilities, 
     habilitation services (including adult day care programs), 
     community treatment teams for individuals with mental 
     illness, home health services, services provided in an 
     institution for mental disease, a Program of All-Inclusive 
     Care for the Elderly (PACE), personal care (including 
     personal assistance services), recovery support including 
     peer counseling, supportive employment, training skills 
     necessary to assist the individual in achieving or 
     maintaining independence, training of family members 
     including foster parents in supportive and behavioral 
     modification skills, ongoing and periodic training to 
     maintain life skills, transitional care including room and 
     board not to exceed 60 days within a 12-month period.
       ``(3) Inclusion of certain benefits under old title xix.--
     Such services and supports may include any of the following 
     services:
       ``(A) Old section 1905(a)(15) (relating to services in an 
     intermediate care facility for the mentally retarded).
       ``(B) Services described in subsections (a)(16) and (h) of 
     old section 1905, but without regard to any restriction on 
     such services on the basis of age (relating to inpatient 
     psychiatric hospital services).
       ``(C) Old section 1905(a)(22) (relating to home and 
     community care (to the extent allowed and as defined in old 
     section 1929) for functionally disabled elderly individuals).
       ``(D) Old section 1905(a)(23) (relating to community 
     supported living arrangements services (to the extent allowed 
     and as defined in old section 1930)).
       ``(E) Subject to subsection (e), old section 1905(a)(24) 
     but without regard to any restriction on furnishing services 
     to patients or residents of facilities or institutions 
     (relating to personal care services).
       ``(F) Old sections 1905(a)(26) and 1934 (relating to 
     services furnished under a PACE program under old section 
     1934 to PACE program eligible individuals enrolled under the 
     program under such old section).
       ``(G) Old section 1915(c)(5) (relating to the definition of 
     habilitation services).
       ``(4) Limitation.--Long-term care services and supports 
     cannot be used for services and administrative costs provided 
     through the foster care (with the exception of training of 
     foster care parents), child welfare, adult protective 
     services, juvenile justice, public guardianship, or 
     correctional systems.
       ``(b) Rehabilitative Care.--For purposes of rehabilitation 
     due to acute care medical needs, a State may claim 
     rehabilitative services provided in an institutional setting, 
     nursing home, or as part of home health expenditures as acute 
     care benefits under the State plan under part A rather than 
     under the State plan under this part for a cumulative period 
     of 30 days within a 12-month period if such care is directly 
     related to the onset of an acute care need. A State shall 
     demonstrate the services were provided as a direct result of 
     an acute care need.
       ``(c) Managed Care.--If a State provides long-term care 
     services and supports through managed care, the State shall 
     submit a methodology for determining the level of 
     expenditures attributed to long term care for approval by the 
     Secretary.
       ``(d) Application of Part A Definitions.--A definition 
     specified in section 1905 shall apply to the same term used 
     in this part, unless the Secretary determines that the 
     application of such definition would be inconsistent with the 
     purpose of this part.
       ``(e) Exclusion.--No payments shall be made under the State 
     plan under this part with respect to long-term care supports 
     and services provided for any individual who is an inmate of 
     a public institution. Nothing in the preceding sentence shall 
     be construed as precluding the provision of long-term care 
     services and supports under the State plan under this part to 
     an individual who is a patient in an institution for mental 
     diseases.

     ``SEC. 1917. PROVISION REQUIREMENTS FOR LONG-TERM CARE 
                   SERVICES AND SUPPORT, INCLUDING OPTION FOR 
                   SELF-DIRECTED SERVICES AND SUPPORTS.

       ``(a) Requirements for the Provision of Long-Term Care 
     Services and Supports.--
       ``(1) In general.--Subject to the succeeding provisions of 
     this subsection, a State may provide through a State plan 
     amendment for the provision of long-term care services and 
     supports for individuals eligible under the State plan under 
     this part, subject to the following requirements:
       ``(A) Needs-based criteria for eligibility for, and receipt 
     of, long-term care services and supports.--The State 
     establishes needs-based criteria for determining an 
     individual's eligibility under the State plan for medical 
     assistance for such long-term care services and supports, and 
     if the individual is eligible for such services and supports, 
     the specific services and supports that will be available 
     under the State plan to the individual.
       ``(B) Criteria for institutionalized versus non-
     institutionalized services.--In establishing needs-based 
     criteria, the State may establish criteria for determining 
     eligibility for, and receipt of, services and supports 
     provided in a facility or institution that are more stringent 
     that the criteria established for eligibility and receipt of 
     services and supports in a non-facility or non-
     institutionalized setting.
       ``(C) Authority to limit number of eligible individuals.--A 
     State may limit the number of individuals who are eligible 
     for such services and supports and may establish waiting 
     lists for the receipt of such services and supports.
       ``(D) Criteria based on individual assessment.--
       ``(i) In general.--The criteria established by the State 
     shall require an assessment of an individual's support needs 
     and capabilities, and may take into account the inability of 
     the individual to perform 2 or more activities of daily 
     living (as defined in section 7702B(c)(2)(B) of the Internal 
     Revenue Code of 1986) or the need for significant assistance 
     to perform such activities, and such other risk factors as 
     the State determines to be appropriate.
       ``(ii) Adjustment authority.--The State plan amendment 
     provides the State with the option to modify the criteria 
     established under subparagraph (A) (without having to obtain 
     prior approval from the Secretary) in the event that the 
     enrollment of individuals eligible for services exceeds the 
     projected enrollment, but only if--

       ``(I) the State provides at least 60 days notice to the 
     Secretary and the public of the proposed modification;
       ``(II) the State deems an individual receiving long-term 
     care services and supports on the basis of the most recent 
     version of the criteria in effect prior to the effective date 
     of the modification to be eligible for such services and 
     supports for a period of at least 12 months beginning on the 
     date the individual first received medical assistance for 
     such services and supports; and
       ``(III) after the effective date of such modification, the 
     State, at a minimum, applies the criteria for determining 
     whether an individual requires the level of care provided in 
     a facility or institutionalized setting which applied under 
     the State plan immediately prior to the application of the 
     modified criteria.

       ``(E) Independent evaluation and assessment.--
       ``(i) Eligibility determination.--The State uses an 
     independent evaluation for making the determinations 
     described in subparagraph (A).
       ``(ii) Assessment.--In the case of an individual who is 
     determined to be eligible for long-term care services and 
     supports, the State uses an independent assessment, based on 
     the needs of the individual to--

       ``(I) determine a necessary level of services and supports 
     to be provided, consistent with an individual's physical and 
     mental capacity;
       ``(II) prevent the provision of unnecessary or 
     inappropriate care; and
       ``(III) establish an individualized care plan for the 
     individual in accordance with subparagraph (G).

       ``(F) Assessment.--The independent assessment required 
     under subparagraph (E)(ii) shall include the following:
       ``(i) An objective evaluation of an individual's inability 
     to perform 2 or more activities of daily living (as defined 
     in section 7702B(c)(2)(B) of the Internal Revenue Code of 
     1986) or the need for significant assistance to perform such 
     activities.
       ``(ii) A face-to-face evaluation of the individual by an 
     individual trained in the assessment and evaluation of 
     individuals whose physical or mental conditions trigger a 
     potential need for long-term care services and supports.
       ``(iii) Where appropriate, consultation with the 
     individual's family, spouse, guardian, or other responsible 
     individual.

[[Page 32802]]

       ``(iv) Consultation with appropriate treating and 
     consulting health and support professionals caring for the 
     individual.
       ``(v) An examination of the individual's relevant history, 
     medical records, and care and support needs, guided by best 
     practices and research on effective strategies that result in 
     improved health and quality of life outcomes.
       ``(vi) An evaluation of the ability of the individual or 
     the individual's representative to self-direct the purchase 
     of, or control the receipt of, such services and supports if 
     the individual so elects.
       ``(G) Individualized care plan.--
       ``(i) In general.--In the case of an individual who is 
     determined to be eligible for long-term care services and 
     supports, the State uses the independent assessment required 
     under subparagraph (E)(ii) to establish a written 
     individualized care plan for the individual.
       ``(ii) Plan requirements.--The State ensures that the 
     individualized care plan for an individual--

       ``(I) is developed--

       ``(aa) in consultation with the individual, the 
     individual's treating physician, health care or support 
     professional, or other appropriate individuals, as defined by 
     the State, and, where appropriate the individual's family, 
     caregiver, or representative; and
       ``(bb) taking into account the extent of, and need for, any 
     family or other supports for the individual;

       ``(II) identifies the long-term care services and supports 
     to be furnished to the individual (or, if the individual 
     elects to self-direct the purchase of, or control the receipt 
     of, such services and supports, funded for the individual); 
     and
       ``(III) is reviewed at least annually and as needed when 
     there is a significant change in the individual's 
     circumstances.

       ``(iii) State requirement to offer election for self-
     directed services and supports.--

       ``(I) Individual choice.--The State shall allow an 
     individual or the individual's representative the opportunity 
     to elect to receive self-directed long-term care services and 
     supports in a manner which gives them the most control over 
     such services and supports consistent with the individual's 
     abilities and the requirements of subclauses (II) and (III).
       ``(II) Self-directed.--The term `self-directed' means, with 
     respect to the long-term care services and supports offered 
     under the State plan amendment, such services and supports 
     for the individual which are planned and purchased under the 
     direction and control of such individual or the individual's 
     authorized representative, including the amount, duration, 
     scope, provider, and location of such services and supports, 
     under the State plan consistent with the following 
     requirements:

       ``(aa) Assessment.--There is an assessment of the needs, 
     capabilities, and preferences of the individual with respect 
     to such services and supports.
       ``(bb) Service plan.--Based on such assessment, there is 
     developed jointly with such individual or the individual's 
     authorized representative a plan for such services and 
     supports for such individual that is approved by the State 
     and that satisfies the requirements of subclause (III).

       ``(III) Plan requirements.--For purposes of subclause 
     (II)(bb), the requirements of this subclause are that the 
     plan--

       ``(aa) specifies those services and supports which the 
     individual or the individual's authorized representative 
     would be responsible for directing;
       ``(bb) identifies the methods by which the individual or 
     the individual's authorized representative will select, 
     manage, and dismiss providers of such services and supports;
       ``(cc) specifies the role of family members and others 
     whose participation is sought by the individual or the 
     individual's authorized representative with respect to such 
     services and supports;
       ``(dd) is developed through a person-centered process that 
     is directed by the individual or the individual's authorized 
     representative, builds upon the individual's capacity to 
     engage in activities that promote community life and that 
     respects the individual's preferences, choices, and 
     abilities, and involves families, friends, and professionals 
     as desired or required by the individual or the individual's 
     authorized representative;
       ``(ee) includes appropriate risk management techniques that 
     recognize the roles and sharing of responsibilities in 
     obtaining services and supports in a self-directed manner and 
     assure the appropriateness of such plan based upon the 
     resources and capabilities of the individual or the 
     individual's authorized representative; and
       ``(ff) may include an individualized budget which 
     identifies the dollar value of the services and supports 
     under the control and direction of the individual or the 
     individual's authorized representative.

       ``(IV) Budget process.--With respect to individualized 
     budgets described in subclause (III)(ff), the State plan 
     amendment--

       ``(aa) describes the method for calculating the dollar 
     values in such budgets based on reliable costs and service 
     utilization;
       ``(bb) defines a process for making adjustments in such 
     dollar values to reflect changes in individual assessments 
     and service plans; and
       ``(cc) provides a procedure to evaluate expenditures under 
     such budgets.
       ``(H) Quality assurance; conflict of interest standards.--
       ``(i) Quality assurance.--The State ensures that the 
     provision of long-term care services and supports meets 
     Federal and State guidelines for quality assurance.
       ``(ii) Conflict of interest standards.--The State 
     establishes standards for the conduct of the independent 
     evaluation and the independent assessment to safeguard 
     against conflicts of interest.
       ``(I) Redeterminations and appeals.--The State allows for 
     at least annual redeterminations of eligibility, and appeals 
     in accordance with the frequency of, and manner in which, 
     redeterminations and appeals of eligibility are made under 
     the State plan.
       ``(J) Presumptive eligibility for assessment.--The State, 
     at its option, elects to provide for a period of presumptive 
     eligibility (not to exceed a period of 60 days) only for 
     those individuals that the State has reason to believe may be 
     eligible for long-term care services and supports. Such 
     presumptive eligibility shall be limited to medical 
     assistance for carrying out the independent evaluation and 
     assessment under subparagraph (E) to determine an 
     individual's eligibility for such services and if the 
     individual is so eligible, the specific long-term care 
     services and supports that the individual will receive.
       ``(2) Definition of individual's representative.--In this 
     section, the term `individual's representative' means, with 
     respect to an individual, a parent, a family member, or a 
     guardian of the individual, an advocate for the individual, 
     or any other individual who is authorized to represent the 
     individual.
       ``(b) Self-Directed Personal Assistance Services.--If a 
     State includes personal care or personal assistance services 
     in the long-term care services and supports available under 
     the State plan, the State shall comply with the requirements 
     of old section 1915(j) in the case of an individual who 
     elects to self-direct the receipt of such care or services.

     ``SEC. 1918. TREATMENT OF INCOME AND RESOURCES FOR CERTAIN 
                   INSTITUTIONALIZED SPOUSES.

       ``Old section 1924 (relating to treatment of income and 
     resources for certain institutionalized spouses), other than 
     paragraphs (2) and (4)(A) of subsection (a) of such section, 
     shall apply under this part.

     ``SEC. 1919. ANNUAL REPORTS.

       ``(a) In General.--Each State that receives payments under 
     this part shall submit an annual report to the Secretary, in 
     such form and manner as the Secretary shall specify.
       ``(b) Requirements.--The report shall include the following 
     with respect to the most recent fiscal year ended:
       ``(1) The number of individuals served under the plan.
       ``(2) The number of individuals served by tier (preventive, 
     emergency, low, medium, and high needs).
       ``(3) The number of individuals known to the State on 
     waiting list for services (if any) and type of disability 
     (physical, developmental, mental health) or aged.
       ``(4) Expenditures by service category.

  ``PART C--GRANTS TO STATES FOR SURVEY AND CERTIFICATION OF MEDICAL 
                   FACILITIES AND OTHER REQUIREMENTS

     ``SEC. 1931. AUTHORIZATION OF APPROPRIATIONS.

       ``For the purpose of carrying our Federal activities and 
     providing grants to States for expenses necessary to carry 
     out this part, there is authorized to be appropriated--
       ``(1) for fiscal year 2011, $300,000,000; and
       ``(2) for each succeeding fiscal year, the amount 
     authorized under this section for the preceding fiscal year, 
     increased by 5 percent.

     ``SEC. 1932. APPLICATION OF CERTAIN REQUIREMENTS UNDER PRE-
                   MODERNIZED MEDICAID.

       ``The following old provisions shall apply under this part:
       ``(1) Old section 1902(a)(9) (relating to health standards 
     and applicable requirements for laboratory services).
       ``(2) Old section 1902(a)(28) (relating to nursing 
     facilities and nursing facility services).
       ``(3) Old sections 1902(a)(29) and 1908 (relating to a 
     State program for the licensing of administrators of nursing 
     homes).
       ``(4) Old section 1902(a)(33)(B) (relating to licensing 
     health institutions).
       ``(5) Old section 1902(d) (relating to medical or 
     utilization review functions).
       ``(6) Old section 1902(i) (relating to intermediate care 
     facilities for the mentally retarded).
       ``(7) Old section 1902(y) (relating to psychiatric 
     hospitals).
       ``(8) Paragraphs (2) and (6) of old section 1903(g) 
     (relating to the Secretarial requirement to conduct sample 
     onsite surveys of private and public institutions and 
     recertifications for the need for certain services).
       ``(9) Old section 1903(q)(4)(B) (relating to the definition 
     of a board and care facility).
       ``(10) Old section 1910 (relating to certification and 
     approval of rural health clinics and intermediate care 
     facilities for the mentally retarded).
       ``(11) Old section 1911 (relating to Indian Health Service 
     facilities).

[[Page 32803]]

       ``(12) Old section 1913 (relating to hospital providers of 
     nursing facility services).
       ``(13) Old section 1919 (relating to requirements for 
     nursing facilities).

            ``PART D--GRANTS TO STATES FOR PROGRAM INTEGRITY

     ``SEC. 1941. AUTHORIZATION OF APPROPRIATIONS.

       ``(a) In General.--For the purpose of carrying out Federal 
     activities under this part and providing grants to States for 
     expenses necessary to carry out this part, there is 
     authorized to be appropriated--
       ``(1) for fiscal year 2011, $100,000,000; and
       ``(2) for each succeeding fiscal year, the amount 
     authorized under this section for the preceding fiscal year, 
     increased by 5 percent.
       ``(b) Availability; Authority for Use of Funds.--
       ``(1) Availability.--Amounts appropriated pursuant to 
     subsection (a) shall remain available until expended.
       ``(2) Authority for use of funds for transportation and 
     travel expenses for attendees at education, training, or 
     consultative activities.--
       ``(A) In general.--The Secretary may use amounts 
     appropriated pursuant to subsection (a) to pay for 
     transportation and the travel expenses, including per diem in 
     lieu of subsistence, at rates authorized for employees of 
     agencies under subchapter I of chapter 57 of title 5, United 
     States Code, while away from their homes or regular places of 
     business, of individuals described in subsection (b)(4) who 
     attend education, training, or consultative activities 
     conducted under the authority of that subsection.
       ``(B) Public disclosure.--The Secretary shall make 
     available on a website of the Centers for Medicare & Medicaid 
     Services that is accessible to the public--
       ``(i) the total amount of funds expended for each 
     conference conducted under the authority of subsection 
     (b)(4); and
       ``(ii) the amount of funds expended for each such 
     conference that were for transportation and for travel 
     expenses.
       ``(c) Annual Report.--Not later than 180 days after the end 
     of each fiscal year, the Secretary shall submit a report to 
     Congress which identifies--
       ``(1) the use of funds appropriated pursuant to subsection 
     (a); and
       ``(2) the effectiveness of the use of such funds.

     ``SEC. 1942. APPLICATION OF CERTAIN REQUIREMENTS UNDER PRE-
                   MODERNIZED MEDICAID.

       ``The following old provisions shall apply under this part:
       ``(1) Old subsections (a)(25) (other than subparagraph (E)) 
     and (g) of section 1902 and section 1903(o) (relating to 
     third party liability).
       ``(2) Old section 1902(a)(30)(B) (relating to hospital, 
     intermediate care facility for the mentally retarded, or 
     hospital for mental diseases admission screening and review 
     requirements).
       ``(3) Old section 1902(a)(32) (relating to certain payment 
     requirements).
       ``(4) Old section 1902(a)(35) (relating to disclosing 
     entities under section 1124).
       ``(5) Old section 1902(a)(37) and the fifth sentence 
     (relating to claims payment procedures).
       ``(6) Old section 1902(a)(44) (relating to payment for 
     inpatient hospital services, services in an intermediate care 
     facility for the mentally retarded, or inpatient mental 
     hospital services).
       ``(7) Old sections 1902(a)(45) and 1912 (relating to 
     assignment of rights of payment).
       ``(8) Old sections 1902(a)(49) and 1921 (relating to 
     information and access to information concerning sanctions 
     taken by State licensing authorities against health care 
     practitioners and providers).
       ``(9) Old sections 1902(a)(61) and 1903(q) (relating to 
     requirements for a medicaid fraud and abuse control unit).
       ``(10) Old section 1902(a)(64) (relating to reports from 
     beneficiaries and others and data compilation requirements 
     concerning alleged instances of waste, fraud, and abuse).
       ``(11) Old section 1902(a)(65) (relating to provider number 
     and surety bond requirement for suppliers of durable medical 
     equipment).
       ``(12) Old section 1902(a)(68) (relating to requirements 
     for certain entities).
       ``(13) Old sections 1902(a)(69) and 1936 (relating to the 
     Medicaid Integrity Program) other than paragraphs (1), 
     (2)(A), and (3) of old section 1936(e).
       ``(14) Old section 1902(a)(70)(B)(iv) (relating to 
     prohibitions on referrals and conflict of interest for 
     certain brokers of non-emergency medical transportation).
       ``(15) Old sections 1902(a)(71) and 1940 (relating to a 
     required asset verification program).
       ``(16) Old section 1902(p) (relating to exclusion of 
     certain individuals or entities).
       ``(17) Old section 1902(x) (relating to unique identifiers 
     for physicians).
       ``(18) Old section 1903(p) (relating to interstate 
     collection of rights of support).
       ``(19) Old section 1903(r)(2) (relating to requirements for 
     mechanized claims processing and information retrieval 
     systems).
       ``(20) Old section 1903(u) (relating to erroneous excess 
     payments), other than clause (v) of paragraph (1)(D).
       ``(21) Old section 1903(v) and the seventh sentence of old 
     section 1902(a) (relating to limitations on payments for 
     services furnished to aliens), other than subparagraphs (A) 
     and (B) of paragraph (4).
       ``(22) Old section 1903(x) (relating to citizenship 
     documentation).
       ``(23) Old section 1909 (relating to State false claims act 
     requirements for increased State share of recoveries).
       ``(24) Old section 1914 (relating to withholding of Federal 
     share of payments for certain Medicare providers).
       ``(25) Old section 1917 (relating to liens, adjustments and 
     recoveries, and transfers of assets).
       ``(26) Old section 1922 (relating to correction and 
     reduction plans for intermediate care facilities for the 
     mentally retarded).

             ``PART E--GRANTS TO STATES FOR ADMINISTRATION

     ``SEC. 1951. AUTHORIZATION OF APPROPRIATIONS; PAYMENTS TO 
                   STATES.

       ``(a) In General.--For the purpose of providing grants to 
     States for administrative expenses necessary to carry out 
     parts A and B, there is authorized to be appropriated--
       ``(1) for fiscal year 2011, $7,000,000,000; and
       ``(2) for each succeeding fiscal year, the amount 
     authorized under this subsection for the preceding fiscal 
     year, increased by 3 percent.
       ``(b) Payments to States.--
       ``(1) In general.--From the amount appropriated pursuant to 
     subsection (a) for a fiscal year, the Secretary shall pay 
     each State with approved plans under parts A and B for the 
     fiscal year an amount equal to the product of the amount 
     appropriated for the fiscal year and the ratio of the total 
     amount of payments made to the State under paragraphs (2) 
     through (7) of section 1903(a) for fiscal year 2008 (as such 
     section was in effect for that fiscal year) to the total 
     amount of such payments made to all States for such fiscal 
     year.
       ``(2) Pro rata adjustment.--The Secretary shall make pro 
     rata adjustments to the amounts determined under paragraph 
     (1) for a fiscal year as necessary so as to not exceed the 
     amount appropriated pursuant to subsection (a) for the fiscal 
     year.

     ``SEC. 1952. COST-SHARING PROTECTIONS.

       ``(a) In General.--A State may impose cost-sharing for 
     individuals provided acute care medical assistance under a 
     State plan under part A or long-term care services and 
     supports under a State plan under part B consistent with the 
     following:
       ``(1) The State may (in a uniform manner) require payment 
     of monthly premiums or other cost-sharing set on a sliding 
     scale based on family income.
       ``(2) A premium or other cost-sharing requirement imposed 
     under paragraph (1) may only apply to the extent that, in the 
     case of an individual whose family income--
       ``(A) exceeds 150 percent of the poverty line, the 
     aggregate annual amount of such premium and other cost-
     sharing charges imposed under the plan does not exceed 5 
     percent of the individual's annual income; and
       ``(B) exceeds 250 percent of the poverty line, the 
     aggregate annual amount of such premium and other cost-
     sharing charges do not exceed 7.5 percent of the individual's 
     annual income.
       ``(3) A State shall not require prepayment of any premium 
     or cost-sharing imposed pursuant to paragraph (1) and shall 
     not terminate eligibility of an individual under the State 
     plan on the basis of failure to pay any such premium or cost-
     sharing until such failure continues for a period of at least 
     60 days from the date on which the premium or cost-sharing 
     became past due. The State may waive payment of any such 
     premium or cost-sharing in any case where the State 
     determines that requiring such payment would create an undue 
     hardship.
       ``(b) Application to Institutionalized Individuals.--A 
     State may impose cost-sharing consistent with subsection (a) 
     to individuals who are patients in, or residents of, a 
     medical institution or nursing facility except that rules 
     relating to the post-eligibility treatment of income 
     (including a minium monthly personal needs allowance) 
     applicable to institutionalized individuals under old title 
     XIX shall apply in the same manner to individuals eligible 
     for long-term care services and supports under a State plan 
     under part B.
       ``(c) Poverty Line Defined.--In this section, the term 
     `poverty line' has the meaning given such term in section 
     673(2) of the Community Services Block Grant Act (42 U.S.C. 
     9902(2)), including any revision required by such section.

     ``SEC. 1953. APPLICATION OF CERTAIN REQUIREMENTS UNDER PRE-
                   MODERNIZED MEDICAID.

       ``The following old provisions shall apply to the State 
     plans under this title:
       ``(1) Old state plan requirements.--
       ``(A) Old section 1902(a)(1) (relating to the requirement 
     for plans to be in effect in all political subdivisions of 
     the State).
       ``(B) Old section 1902(a)(2) (relating to State financial 
     participation).
       ``(C) Old section 1902(a)(3) (relating to opportunity for a 
     fair hearing).
       ``(D) Old section 1902(a)(4) (relating to administration).
       ``(E) Old section 1902(a)(5) (relating to designation of a 
     single State agency).
       ``(F) Old section 1902(a)(6) (relating to reporting 
     requirements).
       ``(G) Old section 1902(a)(7) (relating to restrictions on 
     the use or disclosure of information).

[[Page 32804]]

       ``(H) Old section 1902(a)(8) (relating to applications for 
     assistance).
       ``(I) Old section 1902(a)(11) (relating to cooperative 
     agreements with other State agencies).
       ``(J) Old section 1902(a)(12) (relating to determinations 
     of blindness).
       ``(K) Old section 1902(a)(13) (relating to determination of 
     rates of payment for certain services), other than clause 
     (iv) of subparagraph (A).
       ``(L) Subsections (a)(15) and (bb) of old section 1902(a) 
     (relating to payment for services provided by rural health 
     clinics and federally qualified health centers).
       ``(M) Old section 1902(a)(16) (relating to furnishing 
     services to individuals when absent from the State).
       ``(N) Old section 1902(a)(22) (relating to certain 
     administrative provisions).
       ``(O) Paragraphs (23) and (25)(D) of old section 1902(a) 
     (relating to any willing provider requirements).
       ``(P) Old section 1902(a)(24) (relating to consultative 
     services by other agencies).
       ``(Q) Old section 1902(a)(26) (relating to review of need 
     for inpatient mental hospital services and written plan of 
     care requirements).
       ``(R) Old section 1902(a)(27) (relating to provider record 
     keeping requirements).
       ``(S) Old section 1902(a)(30)(A) (relating to utilization 
     review).
       ``(T) Old section 1902(a)(31) (relating to written plan of 
     care for services and review for intermediate care facility 
     for the mentally retarded services).
       ``(U) Old section 1902(a)(33)(A) (relating to quality 
     review requirements).
       ``(V) Old section 1902(a)(36) (relating to public 
     availability of facility surveys).
       ``(W) Old section 1902(a)(38) (relating to the provision of 
     information described in section 1128(b)(9) by certain 
     entities).
       ``(X) Old section 1902(a)(39) (relating to the exclusion of 
     certain entities).
       ``(Y) Old section 1902(a)(40) (relating to requirement for 
     uniform reporting systems).
       ``(Z) Old section 1902(a)(41) (relating to notice to State 
     medical licensing boards).
       ``(AA) Old section 1902(a)(42) (relating to certain audit 
     requirements).
       ``(BB) Old section 1902(a)(48) (relating to eligibility 
     cards).
       ``(CC) Old section 1902(a)(55) (relating to the receipt and 
     initial processing of applications, but only to the extent 
     such section is consistent with the policy embodied in the 
     State plans under parts A and B).
       ``(DD) Subsections (a)(56) and (s) of old section 1902 
     (relating to adjusted payments for certain inpatient hospital 
     services).
       ``(EE) Old section 1902(a)(59) (relating to maintenance of 
     list of participating physicians).
       ``(FF) The second sentence of old section 1902 (relating to 
     designation of certain State agencies).
       ``(GG) Old section 1902(b) (relating to limitations on 
     approval of plans).
       ``(HH) Old section 1902(j) (relating to application of 
     requirements to American Samoa and the Northern Mariana 
     Islands).
       ``(2) Other old title xix requirements.--
       ``(A) Old section 1903(b)(4) (relating to limitations on 
     payments to enrollment brokers).
       ``(B) Old section 1903(c) (relating to furnishing of 
     services included in a program or plan under part B or C of 
     the Individuals with Disabilities Education Act).
       ``(C) Old section 1903(d) (relating to payments).
       ``(D) Old section 1903(e) (relating to costs with respect 
     to certain hospital services).
       ``(E) Old section 1903(i) (relating to limitations on 
     payments).
       ``(F) Old section 1903(r) (relating to requirements for 
     mechanized claims processing and information retrieval 
     systems).
       ``(G) Subsections (b)(5) and (w) of old section 1903 
     (relating to limitations on payments related to provider 
     taxes).
       ``(H) Old section 1904 (relating to operation of State 
     plans).
       ``(I) Old sections 1902(a)(60) and 1908A (relating to 
     medical child support).
       ``(J) Paragraphs (32)(D) and (62) of old section 1902(a) 
     and section 1928 (relating to program for distribution of 
     pediatric vaccines).

                       ``PART F--OTHER PROVISIONS

     ``SEC. 1961. APPLICATION OF CERTAIN REQUIREMENTS UNDER PRE-
                   MODERNIZED MEDICAID.

       ``The following old provisions shall apply under this part:
       ``(1) The third sentence of old section 1902 (relating to 
     nonapplication of certain old provisions to a religious 
     nonmedical health care institution).
       ``(2) Old section 1918 (relating to application of 
     provisions of title II relating to subpoenas).
       ``(3) Old section 1939 (relating to references to laws 
     directly affecting the Medicaid program.''.
       (b) Repeal of Title XXI.--Effective January 1, 2011, title 
     XXI of the Social Security Act (42 U.S.C. 1397aa et seq.) is 
     repealed.

     SEC. 402. OUTREACH.

       (a) Authorization of Appropriations.--The following amounts 
     are authorized to be appropriated to the Secretary of Health 
     and Human Services:
       (1) For fiscal year 2009, $100,000,000 for the design and 
     implementation of a public outreach campaign to inform the 
     public about the changes to the programs under such titles 
     that take effect on January 1, 2011, as a result of the 
     amendment made by section 401.
       (2) For each of fiscal years 2010 and 2011, $200,000,000 to 
     carry out such public outreach campaign.
       (3) For fiscal year 2012, $50,000,000 to carry out such 
     public outreach campaign.
       (b) Availability.--Funds appropriated under subsection (a) 
     shall remain available for expenditure through September 30, 
     2012.
       (c) Authority for Use of Funds.--The Secretary may use 
     funds made available under paragraphs (2) and (3) of 
     subsection (a) to award grants to, or enter into contracts 
     with, public or private entities, including States, local 
     governments, schools, churches, and community groups.

     SEC. 403. TRANSITION RULES; MISCELLANEOUS PROVISIONS.

       (a) In General.--
       (1) Not later than June 30, 2010, a State that is one of 
     the 50 States or the District of Columbia shall inform all 
     individuals enrolled in a State plan under title XIX or XXI 
     of the Social Security Act on such date (and any new 
     enrollees after such date) of the changes to the programs 
     under such titles that take effect on January 1, 2011, as a 
     result of the amendment made by section 401.
       (2) No State that is one of the 50 States or the District 
     of Columbia shall approve any applications for medical 
     assistance or child health assistance under a State plan 
     under title XIX or XXI (as in effect for fiscal year 2010) 
     after December 31, 2010.
       (b) Submission of Legislative Proposal for Technical and 
     Conforming Amendments.--Not later than 6 months after the 
     date of enactment of this Act, the Secretary of Health and 
     Human Services shall submit to Congress a legislative 
     proposal for such technical and conforming amendments as are 
     necessary to carry out the amendments made by this Act.

Subtitle B--Supplemental Health Care Assistance for Low-Income Families

     SEC. 411. SUPPLEMENTAL HEALTH CARE ASSISTANCE FOR LOW-INCOME 
                   FAMILIES.

       Part D of title III of the Public Health Service Act (42 
     U.S.C. 254b et seq.) is amended by adding at the end the 
     following:

      ``Subpart XI--Health Care Assistance to Low-Income Families

     ``SEC. 340A-1. FINANCIAL ASSISTANCE TO LOW-INCOME FAMILIES.

       ``(a) In General.--The Secretary shall supplement the costs 
     of private health insurance for eligible low-income families 
     through the distribution of supplemental debit cards to 
     eligible families, which may be used to pay for costs 
     associated with health care for the members of such eligible 
     families and provide direct support to such families in 
     accessing health care.
       ``(b) Eligibility.--
       ``(1) Eligible families.--To be eligible for financial 
     assistance under this section--
       ``(A) a family shall--
       ``(i) consist of 2 or more individuals living together who 
     are related by marriage, birth, adoption, or guardianship;
       ``(ii) have a gross income that does not exceed 200 percent 
     of the poverty line, as applicable to a family of the size 
     involved; and
       ``(iii) include at least 1 individual who is a dependent 
     under the age of 19; and
       ``(B) no member of the family shall be covered by private 
     health insurance.
       ``(2) Determination of gross income.--The gross income of a 
     family shall be determined by taking the sum of the income of 
     each family member who is at least age 21 but not older than 
     age 65, except that the income of any member of the family 
     who qualifies for coverage under Medicaid Part A or B shall 
     not be counted.
       ``(3) Limitation on individual eligibility; assistance.--
       ``(A) In general.--No individual who is a member of an 
     eligible family under paragraph (1) is eligible to qualify 
     separately for financial assistance under this section.
       ``(B) Aliens.--The Secretary shall ensure that financial 
     assistance under this section is not provided for costs 
     associated with health care for any member of an eligible 
     family who is an alien individual who is not a lawful 
     permanent resident of the United States.
       ``(c) Supplemental Debit Card for Health Care 
     Expenditures.--
       ``(1) In general.--The Secretary shall issue to each 
     eligible family that enrolls in the program in accordance 
     with subsection (f) a supplemental debit card with a dollar-
     amount value, in accordance with subsection (d), that may be 
     used to pay for qualifying health care expenses.
       ``(2) Use of the debit card.--
       ``(A) Qualifying health care expenses.--A supplemental 
     debit card issued under this section may be used by members 
     of the eligible family to pay for--
       ``(i) the purchase of health care insurance for any member 
     of the family;
       ``(ii) cost sharing expenses related to health care, 
     including deductibles, copayments, and coinsurance, for any 
     member of the family; and
       ``(iii) the direct purchase of health care services and 
     supplies for any member of the family.
       ``(B) Geographic range.--Each supplemental debit card may 
     be used to pay for

[[Page 32805]]

     qualifying health care expenses incurred anywhere in the 50 
     States or the District of Columbia.
       ``(C) Limitations.--No supplemental debit card shall be 
     used to make a payment for any cost--
       ``(i) incurred prior to the determination of the family's 
     eligibility for assistance under this section; or
       ``(ii) that is not a health-related expense.
       ``(3) Rollover of unused amounts.--Not more than one-
     quarter of the annual dollar amount of a supplemental debit 
     card that is unexpended at the end of each 12-month period 
     may rollover--
       ``(A) to the family's supplemental debit card for 
     expenditure during the subsequent 12-month period, provided 
     that the family to which the supplemental debit card was 
     issued in the previous 12-month period is eligible to receive 
     a supplemental debit card in the subsequent 12-month period; 
     or
       ``(B) to the family's health savings account (as defined in 
     section 223(g)(2) of the Internal Revenue Code of 1986).
       ``(4) Monthly statements.--The Secretary shall issue a 
     monthly statement to each family to which a supplemental 
     debit card has been issued under this section, which shall 
     state each payment made with the family's supplemental debit 
     card during the month covered by the statement, the dollar 
     amount of each such payment, and the provider to which each 
     such payment was made.
       ``(d) Amount of Financial Assistance.--
       ``(1) Amounts for calendar year 2011.--Subject to paragraph 
     (5), the amount of financial assistance available to each 
     eligible family during the calendar year 2011 shall be 
     determined as follows:
       ``(A) Each family whose annual income does not exceed 100 
     percent of the poverty level, as applicable to a family of 
     the size involved, shall receive $5,000.
       ``(B) Each family whose annual income exceeds 100 percent, 
     but does not exceed 200 percent, of the poverty level, as 
     applicable to a family of the size involved, shall receive an 
     amount as follows:
       ``(i) For families whose annual income exceeds 100 percent 
     but does not exceed 120 percent, of the poverty level, 
     $4,000.
       ``(ii) For families whose annual income exceeds 120 percent 
     but does not exceed 140 percent, of the poverty level, 
     $3,500.
       ``(iii) For families whose annual income exceeds 140 
     percent but does not exceed 160 percent, of the poverty 
     level, $3,000.
       ``(iv) For families whose annual income exceeds 160 percent 
     but does not exceed 180 percent, of the poverty level, 
     $2,500.
       ``(v) For families whose annual income exceeds 180 percent 
     but does not exceed 200 percent, of the poverty level, 
     $2,000.
       ``(2) Additional amounts.--In addition to the amounts under 
     paragraph (1), subject to paragraph (5), the following 
     amounts shall be added to the supplemental debit cards of 
     qualifying families:
       ``(A) For each pregnancy during which a pregnant woman's 
     family is eligible for assistance under this section, an 
     additional amount of $1,000 shall be added to the family's 
     supplemental debit card, except that no family shall receive 
     such additional $1,000 for any pregnancy for which the family 
     received such amount in the previous 12-month period.
       ``(B) For each member of an eligible family who is less 
     than 1 year old on any day within the calendar year in which 
     the family is eligible for assistance, an additional amount 
     of $500 shall be added to the family's supplemental debit 
     card.
       ``(3) Cost of living adjustments.--In the case of any 
     taxable year beginning in a calendar year after 2011, each 
     dollar amount contained in paragraphs (1) and (2) shall be 
     increased in the same manner as the dollar amounts specified 
     in section 25E(b)(3) of the Internal Revenue Code of 1986 are 
     increased by the blended cost-of-living adjustment determined 
     under subsection (k)(2) of section 25E of the Internal 
     Revenue Code for the taxable year involved.
       ``(4) State option to increase amounts.--At the option of 
     each State, amounts in excess of the annual dollar amounts 
     under paragraphs (1) and (2) may be provided through the 
     supplemental debit card to eligible families in that State, 
     but no Federal funds shall be paid to any State for any 
     amount provided in excess of such annual dollar amount.
       ``(5) Risk adjustment.--The Secretary may adjust the amount 
     of financial assistance available to an eligible family for a 
     calendar year under this section based on age, health 
     indicators, and other factors that represent distinct 
     patterns of health care services utilization and costs.
       ``(e) Contributions of States.--
       ``(1) In general.--As a condition for receiving Federal 
     funds under Part A or Part B of Medicaid, each State shall 
     contribute 50 percent of the total amount expended under the 
     supplemental debit card program by the participating families 
     that reside within the State during the time that the family 
     resides in that State. For purposes of this section, the 
     residency of a family is determined by the residency the 
     legally responsible head of the household.
       ``(2) Payments from states.--
       ``(A) Billing notification.--
       ``(i) Timing.--On June 30th and December 31st of each year, 
     the Secretary shall send written notification to each State 
     of that State's 50 percent share of expenses, as described in 
     paragraph (1), for the 6-month period ending on the last day 
     of the month previous to such notification.
       ``(ii) Contents.--Each such notification to a State shall 
     clearly state--

       ``(I) the payment amount due from the State;
       ``(II) the name of each individual for whom payment was 
     made through the supplemental debit card program;
       ``(III) the health care provider to whom each payment was 
     made;
       ``(IV) the amount of each payment; and
       ``(V) any other information, as the Secretary requires.

       ``(B) Payments.--Each State shall make a payment to the 
     Secretary, in the amount billed, not later than 30 days after 
     the billing notification date, in accordance with 
     subparagraph (A)(i).
       ``(C) Penalties.--If a State fails to pay to the Secretary 
     an amount required under subparagraph (B), interest shall 
     accrue on such amount at the rate provided under old section 
     1903(d)(5) of the Social Security Act. The amount so owed and 
     applicable interest shall be immediately offset against 
     amounts otherwise payable to the State under this section, in 
     accordance with the Federal Claims Collection Act of 1996 and 
     applicable regulations.
       ``(f) Enrollment.--
       ``(1) In general.--The Secretary shall establish procedures 
     and times for enrollment in the supplemental debit card 
     program. Open enrollment shall be available not less than 4 
     times per calendar year.
       ``(2) Transition of individuals enrolled in medicaid or the 
     state children's health insurance program.--
       ``(A) Information from the states.--Each State shall--
       ``(i) not later than June 30, 2010, inform all individuals 
     then enrolled in Medicaid or the State Children's Health 
     Insurance Program (SCHIP), of the changes in effect beginning 
     on January 1, 2011; and
       ``(ii) not later than October 31, 2010, redetermine the 
     eligibility of each individual enrolled in Medicaid or SCHIP, 
     other than those individuals who qualify for Medicaid or 
     SCHIP as disabled, elderly, or a special population, for the 
     supplemental debit card program, according to the eligibility 
     criteria under subsection (b).
       ``(B) Automatic enrollment.--The Secretary shall provide 
     for the automatic enrollment in the supplemental debit card 
     program of all individuals who are enrolled in Medicaid or 
     SCHIP and who have been redetermined by a State under 
     subparagraph (A) to be eligible for Medicaid or SCHIP. Any 
     individual who is determined by a State not to qualify for 
     the supplemental debit card program may retain coverage under 
     Medicaid or SCHIP until June 30, 2011.
       ``(3) Assistance with qualified health insurance credit.--
     Each State shall, to the extent practicable, provide 
     individuals residing within the State with information 
     regarding the qualified health insurance credit described in 
     section 25E of the Internal Revenue Code of 1986, including 
     information regarding eligibility for, and how to claim, such 
     credit.
       ``(g) Administration.--
       ``(1) National system.--The Secretary may enter into 
     contracts or agreements with a State, a consortium of States, 
     or a private entity, including a bank, enrollment broker, or 
     similar entity, to establish and maintain a unified national 
     system to support the processes and transactions necessary to 
     administer this section.
       ``(2) Automated system.--The Secretary shall establish an 
     automated means, such as an electronic benefit transfer 
     system, by which the benefits under this section shall be 
     transferred to eligible families.
       ``(3) Verification of applicant information.--The Secretary 
     may verify information provided by applicants with the 
     appropriate Federal, State, and local agencies, including the 
     Internal Revenue Service, the Social Security Administration, 
     the Department of Labor, and child support enforcement 
     agencies.
       ``(4) Choice counseling.--The Secretary may enter into 
     contracts or agreements with a State, a consortium of a 
     State, or a private entity, including an enrollment broker or 
     community organization or other organization, to educate 
     eligible families about their options and to assist in their 
     enrollment in the supplemental debit card plan.
       ``(5) Appeals.--The Secretary shall establish an 
     independent appeals process, to be administered by an entity 
     separate from the entity that makes initial eligibility 
     determinations, which shall be available to individuals who 
     are denied benefits under the supplemental debit card 
     program.
       ``(6) Resolution of errors.--The Secretary shall provide 
     for a reconciliation process with the States to resolve any 
     errors and adjudicate disputes due to incomplete or false 
     information in a family's application or in the billing 
     process described in subsection (e).
       ``(7) Penalties for false information.--Any person who 
     provides false information to qualify for the supplemental 
     debit card program shall pay a penalty in the amount of 110 
     percent of the amount of assistance

[[Page 32806]]

     paid on behalf of such person and all members of such 
     person's family.
       ``(h) Implementation Plan.--Not later than 6 months after 
     the date of enactment of this section, the Secretary shall 
     submit to Congress a plan for implementing this program 
     during fiscal years 2009-2012.
       ``(i) Authorization of Appropriations.--
       ``(1) Administration of the supplemental debit card 
     program.--To administer the program under this section, there 
     are authorized to be appropriated--
       ``(A) for fiscal year 2009, $300,000,000, for the design of 
     a unified, national system of conducting the supplemental 
     debit card program;
       ``(B) for fiscal year 2010, $1,000,000,000 for start-up 
     costs, including, contracting, hiring and training employees, 
     and testing the program; and
       ``(C) for fiscal year 2011 and each subsequent fiscal year, 
     $3,000,000,000.
       ``(2) Authorization of benefits under the supplemental 
     debit card program.--To provide the supplemental debit card 
     benefits described in this section, there are authorized to 
     be appropriated--
       ``(A) for fiscal year 2011, $24,020,000,000;
       ``(B) for fiscal year 2012, $25,220,000,000;
       ``(C) for fiscal year 2013, $26,480,000,000;
       ``(D) for fiscal year 2014, $27,810,000,000; and
       ``(E) for fiscal year 2015, $29,200,000,000.''.

             TITLE V--FIXING MEDICARE FOR AMERICAN SENIORS

     Subtitle A--Increasing Programmatic Efficiency, Economy, and 
                             Accountability

     SEC. 501. ELIMINATING INEFFICIENCIES AND INCREASING CHOICE IN 
                   MEDICARE ADVANTAGE.

       Part C of title XVIII of the Social Security Act is amended 
     by adding at the end the following new section:


               ``protecting medicare benefits for seniors

       ``Sec. 1860C-2.  (a) Competitive Bidding.--
       ``(1) In general.--In order to promote competition among 
     Medicare Advantage plans and to increase the quality of care 
     furnished under such plans, the Secretary shall establish and 
     implement a competitive bidding mechanism under this part.
       ``(2) Mechanism to begin in 2011.--The mechanism 
     established under paragraph (1) shall apply to all MA 
     organizations and plans beginning in 2011.
       ``(3) No effect on part d benefits.--The mechanism 
     established under paragraph (1) shall not affect the 
     provisions of this part relating to benefits under part D, 
     including the bidding mechanism used for benefits under such 
     part.
       ``(b) Rules for Competitive Bidding Mechanism.--
     Notwithstanding any other provision of this part, the 
     following rules shall apply under the competitive bidding 
     mechanism established under subsection (a).
       ``(1) Benchmark.--Benchmark amounts for an area for a year 
     shall be established solely through the competitive bids of 
     MA plans. The benchmark amount for each area for a year shall 
     be the average bid of the plans in that area for that year. 
     In establishing the benchmark for an area for a year under 
     the preceding sentence, the Secretary shall exclude the 
     highest and lowest bid for that area and year. The benchmark 
     amount for an area for a year may not exceed the benchmark 
     amount for that area and year that would have applied if this 
     section had not been enacted.
       ``(2) Bids.--The MA plan bid shall reflect the per capita 
     payments that the MA plan will accept for providing a benefit 
     package that is actuarially equivalent to 106 percent of the 
     value of the original Medicare fee-for-service program 
     option. MA plan bid submissions shall include data on plan 
     average provider network contract rates compared to the rates 
     under the original Medicare fee-for-service program option 
     for the top 5 most common claim submissions per provider 
     type.
       ``(3) Risk adjustment.--The benchmark under paragraph (1) 
     and the MA plan bid shall be risk adjusted using the risk 
     adjustment requirements under this part.
       ``(4) Beneficiary premiums.--The MA monthly basic 
     beneficiary premium for a beneficiary who enrolls in an MA 
     plan whose plan bid is at or below the benchmark shall be 
     zero and the beneficiary shall receive the full difference 
     (if any) between the bid and the benchmark in the form of 
     additional benefits or as a rebate on their premiums under 
     this title. The MA monthly basic beneficiary premium for a 
     beneficiary who enrolls in an MA plan whose plan bid is above 
     the benchmark shall be equal to the amount by which the bid 
     exceeds the benchmark.
       ``(5) Benchmark amounts for rural counties.--The Secretary 
     may adjust the benchmark amount established under paragraph 
     (1) for any rural county (as identified by the Secretary 
     after consultation with the Secretary of Commerce) to 
     encourage plan participation in such county.
       ``(6) Existing requirements.--Requirements relating to 
     licensure, quality, and beneficiary protections that would 
     otherwise apply under this part shall apply under the 
     competitive bidding mechanism established under subsection 
     (a).
       ``(c) Waiver.--In order to implement the competitive 
     bidding mechanism under established subsection (a), the 
     Secretary may waive or modify requirements under this 
     part.''.

     SEC. 502. MEDICARE ACCOUNTABLE CARE ORGANIZATION 
                   DEMONSTRATION PROGRAM.

       (a) Establishment.--
       (1) In general.--In order to promote innovative care 
     coordination and delivery that is cost-effective, the 
     Secretary of Health and Human Services (in this section 
     referred to as the ``Secretary'') shall conduct a 
     demonstration program under the Medicare program under 
     which--
       (A) groups of providers meeting certain criteria may work 
     together to manage and coordinate care for Medicare fee-for-
     service beneficiaries through an Accountable Care 
     Organization (in this section referred to as an ``ACO''); and
       (B) providers in participating ACOs are eligible for 
     bonuses based on performance.
       (2) Medicare fee-for-service beneficiary defined.--In this 
     section, the term ``Medicare fee-for-service beneficiary'' 
     means an individual who is enrolled in the original medicare 
     fee-for-service program under parts A and B of title XVIII of 
     the Social Security Act and not enrolled in an MA plan under 
     part C of such title.
       (b) Eligible ACOs.--
       (1) In general.--Subject to paragraph (2), the following 
     provider groups are eligible to participate as ACOs under the 
     demonstration program under this section:
       (A) Physicians in group practice arrangements.
       (B) Networks of individual physician practices.
       (C) Partnerships or joint venture arrangements between 
     hospitals and physicians.
       (D) Partnerships or joint ventures, which may include 
     pharmacists providing medication therapy management.
       (E) Hospitals employing physicians.
       (F) Integrated delivery systems.
       (G) Community-based coalitions of providers.
       (2) Requirements.--An ACO shall meet the following 
     requirements:
       (A) The ACO shall have a formal legal structure that would 
     allow the organization to receive and distribute bonuses to 
     participating providers.
       (B) The ACO shall include the primary care providers of at 
     least 5,000 Medicare fee-for-service beneficiaries.
       (C) The ACO shall be willing to become accountable for the 
     overall care of the Medicare fee-for-service beneficiaries.
       (D) The ACO shall provide the Secretary with a list of 
     primary care and specialist physicians participating in the 
     ACO to support the beneficiary assignment, implementation of 
     performance measures, and the determination of bonus payments 
     under the demonstration program.
       (E) The ACO shall have in place contracts with a core group 
     of key specialist physicians, a leadership and management 
     structure, and processes to promote evidence-based medicine 
     and to coordinate care.
       (c) Assignment of Medicare Fee-for-Service Beneficiaries.--
       (1) In general.--Under the demonstration program under this 
     section, each Medicare fee-for-service Medicare beneficiary 
     shall be automatically assigned to a primary care provider. 
     Such assignment shall be based on the physician from whom the 
     beneficiary received the most primary care in the preceding 
     year.
       (2) Beneficiaries may continue to see providers outside of 
     the aco.--Under the demonstration program under this section, 
     a Medicare fee-for-service Medicare beneficiary may continue 
     to see providers in and outside of the ACO to which they have 
     been assigned.
       (d) Bonus Payments.--
       (1) In general.--Under the demonstration program, Medicare 
     payments shall continue to be made to providers under the 
     original Medicare fee-for-service program in the same manner 
     as they would otherwise be made except that a participating 
     ACO is eligible for bonuses if--
       (A) it meets certain quality performance measures; and
       (B) spending for their Medicare fee-for-service 
     beneficiaries meets the requirement under paragraph (3).
       (2) Quality.--Under the demonstration program under this 
     section, providers meet the requirement under paragraph 
     (1)(A) if they generally follow consensus-based guidelines 
     established by non-government professional medical societies. 
     Patient satisfaction and risk-adjusted outcomes shall be 
     determined through an independent entity with medical 
     expertise.
       (3) Requirement relating to spending.--
       (A) In general.--An ACO shall only be eligible to receive a 
     bonus payment if the average Medicare expenditures under the 
     ACO for Medicare fee-for-service beneficiaries over a two-
     year period is at least 2 percent below the average benchmark 
     for the corresponding two-year period. The benchmark for each 
     ACO shall be set using the most recent three years of total 
     per-beneficiary spending for Medicare fee-for-service 
     beneficiaries assigned to the ACO. Such benchmark shall be 
     updated by the projected rate of growth in national per 
     capita spending for the original medicare fee-for-service 
     program, as projected (using the most recent three years of 
     data) by the Chief Actuary of

[[Page 32807]]

     the Centers for Medicare & Medicaid Services.
       (4) Amount of bonus payments.--The amount of the bonus 
     payment to a participating ACO shall be one-half of the 
     percentage point difference between the two-year average of 
     their patients' Medicare expenditures and 98 percent of the 
     two-year average benchmark. The bonus amount, in dollars, 
     shall be equal to the bonus share multiplied by the benchmark 
     for the most recent year.
       (5) Limitation.--Bonus payments may only be made to an ACO 
     if the primary care provider to which the Medicare fee-for-
     service beneficiary has been assigned under subsection (c) 
     elects to participate in such ACO.
       (e) Waiver Authority.--The Secretary may waive such 
     requirements of titles XI and XVIII of the Social Security 
     Act (42 U.S.C. 1301 et seq.; 1395 et seq.) as may be 
     appropriate for the purpose of carrying out the demonstration 
     program under this section.
       (f) Report.--Upon completion of the demonstration program 
     under this section, the Secretary shall submit to Congress a 
     report on the program together with such recommendations as 
     the Secretary determines appropriate.

     SEC. 503. REDUCING GOVERNMENT HANDOUTS TO WEALTHIER SENIORS.

       (a) Elimination of Annual Indexing of Income Thresholds for 
     Reduced Part B Premium Subsidies.--
       (1) In general.--Paragraph (5) of section 1839(i) of the 
     Social Security Act (42 U.S.C. 1395r(i)) is repealed.
       (2) Effective date.--The repeal made by paragraph (1) shall 
     apply to premiums for months beginning after December 2010.
       (b) Income-Related Reduction in Part D Premium Subsidy.--
       (1) Income-related reduction in part d premium subsidy.--
       (A) In general.--Section 1860D-13(a) of the Social Security 
     Act (42 U.S.C. 1395w-113(a)) is amended by adding at the end 
     the following new paragraph:
       ``(7) Reduction in premium subsidy based on income.--
       ``(A) In general.--In the case of an individual whose 
     modified adjusted gross income exceeds the threshold amount 
     applicable under paragraph (2) of section 1839(i) (including 
     application of paragraph (5) of such section) for the 
     calendar year, the monthly amount of the premium subsidy 
     applicable to the premium under this section for a month 
     after December 2010 shall be reduced (and the monthly 
     beneficiary premium shall be increased) by the monthly 
     adjustment amount specified in subparagraph (B).
       ``(B) Monthly adjustment amount.--The monthly adjustment 
     amount specified in this subparagraph for an individual for a 
     month in a year is equal to the product of--
       ``(i) the quotient obtained by dividing--

       ``(I) the applicable percentage determined under paragraph 
     (3)(C) of section 1839(i) (including application of paragraph 
     (5) of such section) for the individual for the calendar year 
     reduced by 25.5 percent; by
       ``(II) 25.5 percent; and

       ``(ii) the base beneficiary premium (as computed under 
     paragraph (2)).
       ``(C) Modified adjusted gross income.--For purposes of this 
     paragraph, the term `modified adjusted gross income' has the 
     meaning given such term in subparagraph (A) of section 
     1839(i)(4), determined for the taxable year applicable under 
     subparagraphs (B) and (C) of such section.
       ``(D) Determination by commissioner of social security.--
     The Commissioner of Social Security shall make any 
     determination necessary to carry out the income-related 
     reduction in premium subsidy under this paragraph.
       ``(E) Procedures to assure correct income-related reduction 
     in premium subsidy.--
       ``(i) Disclosure of base beneficiary premium.--Not later 
     than September 15 of each year beginning with 2010, the 
     Secretary shall disclose to the Commissioner of Social 
     Security the amount of the base beneficiary premium (as 
     computed under paragraph (2)) for the purpose of carrying out 
     the income-related reduction in premium subsidy under this 
     paragraph with respect to the following year.
       ``(ii) Additional disclosure.--Not later than October 15 of 
     each year beginning with 2010, the Secretary shall disclose 
     to the Commissioner of Social Security the following 
     information for the purpose of carrying out the income-
     related reduction in premium subsidy under this paragraph 
     with respect to the following year:

       ``(I) The modified adjusted gross income threshold 
     applicable under paragraph (2) of section 1839(i) (including 
     application of paragraph (5) of such section).
       ``(II) The applicable percentage determined under paragraph 
     (3)(C) of section 1839(i) (including application of paragraph 
     (5) of such section).
       ``(III) The monthly adjustment amount specified in 
     subparagraph (B).
       ``(IV) Any other information the Commissioner of Social 
     Security determines necessary to carry out the income-related 
     reduction in premium subsidy under this paragraph.

       ``(F) Rule of construction.--The formula used to determine 
     the monthly adjustment amount specified under subparagraph 
     (B) shall only be used for the purpose of determining such 
     monthly adjustment amount under such subparagraph.''.
       (B) Collection of monthly adjustment amount.--Section 
     1860D-13(c) of the Social Security Act (42 U.S.C. 1395w-
     113(c)) is amended--
       (i) in paragraph (1), by striking ``(2) and (3)'' and 
     inserting ``(2), (3), and (4)''; and
       (ii) by adding at the end the following new paragraph:
       ``(4) Collection of monthly adjustment amount.--
       ``(A) In general.--Notwithstanding any provision of this 
     subsection or section 1854(d)(2), subject to subparagraph 
     (B), the amount of the income-related reduction in premium 
     subsidy for an individual for a month (as determined under 
     subsection (a)(7)) shall be paid through withholding from 
     benefit payments in the manner provided under section 1840.
       ``(B) Agreements.--In the case where the monthly benefit 
     payments of an individual that are withheld under 
     subparagraph (A) are insufficient to pay the amount described 
     in such subparagraph, the Commissioner of Social Security 
     shall enter into agreements with the Secretary, the Director 
     of the Office of Personnel Management, and the Railroad 
     Retirement Board as necessary in order to allow other 
     agencies to collect the amount described in subparagraph (A) 
     that was not withheld under such subparagraph.''.
       (2) Conforming amendments.--
       (A) Medicare.--Part D of title XVIII of the Social Security 
     Act (42 U.S.C. 1395w-101 et seq.) is amended--
       (i) in section 1860D-13(a)(1)--

       (I) by redesignating subparagraph (F) as subparagraph (G);
       (II) in subparagraph (G), as redesignated by subparagraph 
     (A), by striking ``(D) and (E)'' and inserting ``(D), (E), 
     and (F)''; and
       (III) by inserting after subparagraph (E) the following new 
     subparagraph:

       ``(F) Increase based on income.--The monthly beneficiary 
     premium shall be increased pursuant to paragraph (7).''; and
       (ii) in section 1860D-15(a)(1)(B), by striking ``paragraph 
     (1)(B)'' and inserting ``paragraphs (1)(B) and (1)(F)''.
       (B) Internal revenue code.--Section 6103(l)(20) of the 
     Internal Revenue Code of 1986 (relating to disclosure of 
     return information to carry out Medicare part B premium 
     subsidy adjustment) is amended--
       (i) in the heading, by striking ``part b premium subsidy 
     adjustment'' and inserting ``parts b and d premium subsidy 
     adjustments'';
       (ii) in subparagraph (A)--

       (I) in the matter preceding clause (i), by inserting ``or 
     1860D-13(a)(7)'' after ``1839(i)''; and
       (II) in clause (vii), by inserting after ``subsection (i) 
     of such section'' the following: ``or under section 1860D-
     13(a)(7) of such Act'';

       (iii) in subparagraph (B)--

       (I) by inserting ``or such section 1860D-13(a)(7)'' before 
     the period at the end;
       (II) as amended by clause (i), by inserting ``or for the 
     purpose of resolving tax payer appeals with respect to any 
     such premium adjustment'' before the period at the end; and
       (III) by adding at the end the following new sentence: 
     ``Officers, employees, and contractors of the Social Security 
     Administration may disclose such return information to 
     officers, employees, and contractors of the Department of 
     Health and Human Services, the Office of Personnel 
     Management, the Railroad Retirement Board, the Department of 
     Justice, and the courts of the United States to the extent 
     necessary to carry out the purposes described in the 
     preceding sentence.''; and

       (iv) by adding at the end the following new subparagraph:
       ``(C) Timing of disclosure.--Return information shall be 
     disclosed to officers, employees, and contractors of the 
     Social Security Administration under subparagraph (A) not 
     later than the date that is 90 days prior to the date on 
     which the taxpayer first becomes entitled to benefits under 
     part A of title XVIII of the Social Security Act or eligible 
     to enroll for benefits under part B of such title.''.

     SEC. 504. REWARDING PREVENTION.

       Section 1839 of the Social Security Act (42 U.S.C. 1395r) 
     is amended--
       (1) in subsection (a)(2), by striking ``and (i)'' and 
     inserting ``(i), and (j)''; and
       (2) by adding at the end the following new subsection:
       ``(j)(1) With respect to the monthly premium amount for 
     months after December 2010, the Secretary may adjust (under 
     procedures established by the Secretary) the amount of such 
     premium for an individual based on whether or not the 
     individual participates in certain healthy behaviors, such as 
     weight management, exercise, nutrition counseling, refraining 
     from tobacco use, designating a health home, and other 
     behaviors determined appropriate by the Secretary.
       ``(2) In making the adjustments under paragraph (1) for a 
     month, the Secretary shall ensure that the total amount of 
     premiums to be paid under this part for the month is equal to 
     the total amount of premiums that would have been paid under 
     this part for the month if no such adjustments had been made, 
     as estimated by the Secretary.''.

[[Page 32808]]



     SEC. 505. PROMOTING HEALTHCARE PROVIDER TRANSPARENCY.

       (a) Transparency.--Title XVIII of the Social Security Act 
     is amended by adding at the end the following new section:


                   ``price transparency requirements

       ``Sec. 1899.  (a) Pre-Treatment Disclosure.--A provider of 
     services (as defined in section 1861(u)) and a supplier (as 
     defined in section 1861(d)) shall provide to each individual 
     (regardless of whether or not the individual is a beneficiary 
     under this title) who is scheduled to receive a treatment (or 
     to begin a course of treatment) that is not for an emergency 
     medical condition the estimated price that the provider of 
     services or supplier will charge for the treatment (or course 
     of treatment). Such price shall be determined at the time of 
     scheduling.
       ``(b) Post-Treatment Disclosure.--A provider of services 
     (as so defined) and a supplier (as so defined) shall include 
     with any bill that includes the charges for a treatment with 
     respect to an individual (regardless of whether or not the 
     individual is a beneficiary under this title), an itemized 
     list of component charges for such treatment, including 
     charges for drugs and medical equipment involved, as 
     determined at the time of billing. With respect to each item 
     included on such list, the provider of services or supplier 
     shall include the price charged for the item.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to providers of services and suppliers on and 
     after January 1, 2011.

     SEC. 506. AVAILABILITY OF MEDICARE AND MEDICAID CLAIMS AND 
                   PATIENT ENCOUNTER DATA.

       (a) Public Availability.--Not later than 1 year after the 
     date of enactment of this Act (and annually thereafter), the 
     Secretary of Health and Human Services (in this section 
     referred to as the ``Secretary''), shall make available to 
     the public (including through an Internet website) data on 
     claims and patient encounters under titles XVIII and XIX of 
     the Social Security Act during the preceding calendar year. 
     Such data shall be appropriately disaggregated and patient 
     deidentified, as determined necessary by the Secretary in 
     order to comply with the Federal regulations (concerning the 
     privacy of individually identifiable health information) 
     promulgated under section 264(c) of the Health Insurance 
     Portability and Accountability Act of 1996.
       (b) Provision of Data to State Exchanges and Health 
     Insurance Issuers Under the State Exchange.--The Secretary 
     shall submit such data directly to a State Exchange under 
     title II and health insurance issuers under such Exchange (in 
     a form and manner determined appropriate by the Secretary).
       (c) Matching of Data.--The Secretary shall ensure that the 
     total amount of claims under such titles during the preceding 
     year for which data is made available under subsection (a) is 
     equal to the reported outlays from the Federal government and 
     the States under such titles during the preceding years.

                  Subtitle B--Reducing Fraud and Abuse

     SEC. 511. REQUIRING THE SECRETARY OF HEALTH AND HUMAN 
                   SERVICES TO CHANGE THE MEDICARE BENEFICIARY 
                   IDENTIFIER USED TO IDENTIFY MEDICARE 
                   BENEFICIARIES UNDER THE MEDICARE PROGRAM.

       (a) Procedures.--
       (1) In general.--Not later than 1 year after the date of 
     enactment of this Act, in order to protect beneficiaries from 
     identity theft, the Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     establish and implement procedures to change the Medicare 
     beneficiary identifier used to identify individuals entitled 
     to benefits under part A of title XVIII of the Social 
     Security Act or enrolled under part B of such title so that 
     such an individual's social security account number is not 
     used. Such procedures shall provide that the new Medicare 
     beneficiary identifier includes biometric identification 
     protections.
       (2) Maintaining existing hicn structure.--In order to 
     minimize the impact of the change under paragraph (1) on 
     systems that communicate with Medicare beneficiary 
     eligibility systems, the procedures under paragraph (1) shall 
     provide that the new Medicare beneficiary identifier maintain 
     the existing Health Insurance Claim Number structure.
       (3) Protection against fraud.--The procedures under 
     paragraph (1) shall provide for a process for changing the 
     Medicare beneficiary identifier for an individual to a 
     different identifier in the case of the discovery of fraud, 
     including identity theft.
       (4) Phase-in authority.--
       (A) In general.--Subject to subparagraphs (B) and (C), the 
     Secretary may phase in the change under paragraph (1) in such 
     manner as the Secretary determines appropriate.
       (B) Limit.--The phase-in period under subparagraph (A) 
     shall not exceed 10 years.
       (C) Newly entitled and enrolled individuals.--The Secretary 
     shall ensure that the change under paragraph (1) is 
     implemented not later than January 1, 2010, with respect to 
     any individual who first becomes entitled to benefits under 
     part A of title XVIII of the Social Security Act or enrolled 
     under part B of such title on or after such date.
       (b) Education and Outreach.--The Secretary shall establish 
     a program of education and outreach for individuals entitled 
     to, or enrolled for, benefits under part A of title XVIII of 
     the Social Security Act or enrolled under part B of such 
     title, providers of services (as defined in subsection (u) of 
     section 1861 of such Act (42 U.S.C. 1395x)), and suppliers 
     (as defined in subsection (d) of such section) on the change 
     under paragraph (1).
       (c) Data Matching.--
       (1) Access to certain information.--Section 205(r) of the 
     Social Security Act (42 U.S.C. 405(r)) is amended by adding 
     at the end the following new paragraph:
       ``(9)(A) The Commissioner of Social Security shall, upon 
     the request of the Secretary--
       ``(i) enter into an agreement with the Secretary for the 
     purpose of matching data in the system of records of the 
     Commissioner with data in the system of records of the 
     Secretary, so long as the requirements of subparagraphs (A) 
     and (B) of paragraph (3) are met, in order to determine--
       ``(I) whether a beneficiary under the program under title 
     XVIII, XIX, or XXI is dead, imprisoned, or otherwise not 
     eligible for benefits under such program; and
       ``(II) whether a provider of services or a supplier under 
     the program under title XVIII, XIX, or XXI is dead, 
     imprisoned, or otherwise not eligible to furnish or receive 
     payment for furnishing items and services under such program; 
     and
       ``(ii) include in such agreement safeguards to assure the 
     maintenance of the confidentiality of any information 
     disclosed and procedures to permit the Secretary to use such 
     information for the purpose described in clause (i).
       ``(B) Information provided pursuant to an agreement under 
     this paragraph shall be provided at such time, in such place, 
     and in such manner as the Commissioner determines 
     appropriate.
       ``(C) Information provided pursuant to an agreement under 
     this paragraph shall include information regarding whether--
       ``(i) the name (including the first name and any family 
     name or surname), the date of birth (including the month, 
     day, and year), and social security number of an individual 
     provided to the Commissioner match the information contained 
     in the Commissioner's records, and
       ``(ii) such individual is shown on the records of the 
     Commissioner as being deceased.''.
       (2) Investigation based on certain information.--Title XI 
     of the Social Security Act (42 U.S.C. 1301 et seq.) is 
     amended by inserting after section 1128F the following new 
     section:

     ``SEC. 1128G. ACCESS TO CERTAIN DATA AND INVESTIGATION OF 
                   CLAIMS INVOLVING INDIVIDUALS WHO ARE NOT 
                   ELIGIBLE FOR BENEFITS OR ARE NOT ELIGIBLE 
                   PROVIDERS OF SERVICES OR SUPPLIERS.

       ``(a) Data Agreement.--The Secretary shall enter into an 
     agreement with the Commissioner of Social Security pursuant 
     to section 205(r)(9).
       ``(b) Investigation of Claims Involving Certain Individuals 
     Who Are Not Eligible for Benefits or Are Not Eligible 
     Providers of Services or Suppliers.--
       ``(1) In general.--The Secretary shall, in the case where a 
     provider of services or a supplier under the program under 
     title XVIII, XIX, or XXI submits a claim for payment for 
     items or services furnished to an individual who the 
     Secretary determines, as a result of information provided 
     pursuant to such agreement, is not eligible for benefits 
     under such program, or where the Secretary determines, as a 
     result of such information, that such provider of services or 
     supplier is not eligible to furnish or receive payment for 
     furnishing such items or services, conduct an investigation 
     with respect to the provider of services or supplier. If the 
     Secretary determines further action is appropriate, the 
     Secretary shall refer the investigation to the Inspector 
     General of the Department of Health and Human Services as 
     soon as practicable.
       ``(2) Assessment of implementation and effectiveness by the 
     oig.--The Inspector General of the Department of Health and 
     Human Services shall test the implementation of the 
     provisions of this section (including the implementation of 
     the agreement under section 205(r)(9)) and conduct such 
     period assessments of such implementation as the Inspector 
     General determines necessary to determine the effectiveness 
     of such implementation.''.
       (d) Authorization of Appropriations.--There are authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.

     SEC. 512. USE OF TECHNOLOGY FOR REAL-TIME DATA REVIEW.

       Title XVIII of the Social Security Act, as amended by this 
     Act, is amended by adding at the end the following new 
     section:


             ``use of technology for real-time data review

       ``Sec. 1899A.  (a) In General.--The Secretary shall 
     establish procedures for the use of technology (including 
     front-end, pre-payment technology similar to that used by 
     hedge funds, investment funds, and banks) to provide real-
     time data analysis of claims for payment under this title to 
     identify and investigate unusual billing or order practices

[[Page 32809]]

     under this title that could indicate fraud or abuse.
       ``(b) Competitive Bidding.--The procedures established 
     under subsection (a) shall ensure that the implementation of 
     such technology is conducted through a competitive bidding 
     process.''.

     SEC. 513. DETECTION OF MEDICARE FRAUD AND ABUSE.

       (a) In General.--Section 1893 of the Social Security Act 
     (42 U.S.C. 1395ddd) is amended--
       (1) in subsection (b), by adding at the end the following 
     new paragraph:
       ``(7) Implementation of fraud and abuse detection methods 
     under subsection (i).'';
       (2) in subsection (c), by adding at the end of the flush 
     matter following paragraph (4), the following new sentence 
     ``In the case of an activity described in subsection (b)(8), 
     an entity shall only be eligible to enter into a contract 
     under the Program to carry out the activity if the entity is 
     selected through a competitive bidding process in accordance 
     with subsection (i)(3).''; and
       (3) by adding at the end the following new subsection:
       ``(i) Detection of Medicare Fraud and Abuse.--
       ``(1) Establishment of system to identify counties most 
     vulnerable to fraud.--Not later than 6 months after the date 
     of enactment of this subsection, the Secretary shall 
     establish a system to identify the 50 counties most 
     vulnerable to fraud with respect to items and services 
     furnished by providers of services (other than hospitals and 
     critical access hospitals) and suppliers based on the degree 
     of county-specific reimbursement and analysis of payment 
     trends under this title. The Secretary shall designate the 
     counties identified under the preceding sentence as `high 
     risk areas'.
       ``(2) Fraud and abuse detection.--
       ``(A) Initial implementation.--The Secretary shall 
     establish procedures for the implementation of fraud and 
     abuse detection methods under this title with respect to 
     items and services furnished by such providers of services 
     and suppliers in high risk areas designated under paragraph 
     (1) (and, beginning not later than 18 months after the date 
     of enactment of this subsection, with respect to items and 
     services furnished by such providers of services and 
     suppliers in areas not so designated) including the 
     following:
       ``(i) Data analysis to establish prepayment claim edits 
     designed to target the claims for payment under this title 
     for such items and services that are most likely to be 
     fraudulent.
       ``(ii) Prepayment benefit integrity reviews for claims for 
     payment under this title for such items and services that are 
     suspended as a result of such edits.
       ``(B) Requirement for participation.--In no case may a 
     provider of services or supplier who does not meet the 
     requirements under subparagraph (A) participate in the 
     program under this title.
       ``(C) Expanded implementation.--Not later than 24 months 
     after the date of enactment of this subsection, the Secretary 
     shall establish procedures for the implementation of such 
     fraud and abuse detection methods under this title with 
     respect to items and services furnished by all providers of 
     services and suppliers, including those not in high risk 
     areas designated under paragraph (1).
       ``(3) Competitive bidding.--In selecting entities to carry 
     out this subsection, the Secretary shall use a competitive 
     bidding process.
       ``(4) Report to congress.--The Secretary shall submit to 
     Congress an annual report on the effectiveness of activities 
     conducted under this subsection, including a description of 
     any savings to the program under this title as a result of 
     such activities and the overall administrative cost of such 
     activities and a determination as to the amount of funding 
     needed to carry out this subsection for subsequent fiscal 
     years, together with recommendations for such legislation and 
     administrative action as the Secretary determines 
     appropriate.''.
       (b) Authorization of Appropriations.--To carry out the 
     amendments made by this section, there are authorized to be 
     appropriated--
       (1) such sums as may be necessary, not to exceed 
     $50,000,000, for each of fiscal years 2010 through 2014; and
       (2) such sums as may be necessary, not to exceed an amount 
     the Secretary determines appropriate in the most recent 
     report submitted to Congress under section 1893(j)(4) of the 
     Social Security Act, as added by subsection (a), for each 
     subsequent fiscal year.

     SEC. 514. EDITS ON 855S MEDICARE ENROLLMENT APPLICATION AND 
                   EXEMPTION OF PHARMACISTS FROM SURETY BOND 
                   REQUIREMENT.

       (a) Edits on 855S Medicare Enrollment Application.--Section 
     1834(a) of the Social Security Act (42 U.S.C. 1395m(a)) is 
     amended by adding at the end the following new paragraphs:
       ``(22) Confirmation with national supplier clearinghouse 
     prior to payment.--
       ``(A) In general.--Not later than 1 year after the date of 
     enactment of this paragraph, the Secretary shall establish 
     procedures to require carriers, prior to paying a claim for 
     payment for durable medical equipment, prosthetics, 
     orthotics, and supplies under this title, to confirm with the 
     National Supplier Clearinghouse--
       ``(i) that the National Provider Identifier of the 
     physician or practitioner prescribing or ordering the item or 
     service is valid and active;
       ``(ii) that the Medicare identification number of the 
     supplier is valid and active; and
       ``(iii) that the item or service for which the claim for 
     payment is submitted was properly identified on the CMS-855S 
     Medicare enrollment application.
       ``(B) Online database for implementation.--Not later than 
     18 months after the date of enactment of this paragraph, the 
     Secretary shall establish an online database similar to that 
     used for the National Provider Identifier to enable providers 
     of services, accreditors, carriers, and the National Supplier 
     Clearinghouse to view information on specialties and the 
     types of items and services each supplier has indicated on 
     the CMS-855S Medicare enrollment application submitted by the 
     supplier.
       ``(C) Notification of claim denial and resubmission.--In 
     the case where a claim for payment for durable medical 
     equipment, prosthetics, orthotics, and supplies under this 
     title is denied because the item or service furnished does 
     not correctly match up with the information on file with the 
     National Supplier Clearinghouse--
       ``(i) the National Supplier Clearinghouse shall--

       ``(I) provide the supplier written notification of the 
     reason for such denial; and
       ``(II) allow the supplier 60 days to provide the National 
     Supplier Clearinghouse with appropriate certification, 
     licensing, or accreditation; and

       ``(ii) the Secretary shall waive applicable requirements 
     relating to the time frame for the submission of claims for 
     payment under this title in order to permit the resubmission 
     of such claim if payment of such claim would otherwise be 
     allowed under this title.
       ``(D) Improvements to medicare enrollment application.--The 
     Secretary shall establish procedures under which a 
     prospective supplier of durable medical equipment, 
     prosthetics, orthotics, and supplies under this title shall 
     certify, as part of the CMS-855S Medicare enrollment 
     application submitted by such supplier, under penalty of 
     perjury, that the information provided by the supplier on 
     such application is accurate to the best of the supplier's 
     knowledge.
       ``(23) Termination of participation for submission of 
     fraudulent claims.--If the Secretary finds that a supplier of 
     durable medical equipment, prosthetics, orthotics, and 
     supplies under this title has submitted fraudulent claims for 
     payment under this title, the Secretary shall terminate the 
     suppliers participation under this title. Not later than 1 
     year after the date of enactment of this paragraph, the 
     Secretary shall establish a process under which a supplier 
     whose participation has been terminated under the preceding 
     sentence may appeal such termination and such appeal shall be 
     resolved not later than 60 days after the date on which the 
     appeal was made.''.
       (b) Exemption of Pharmacists From Surety Bond 
     Requirement.--Section 1834(a)(16) of the Social Security Act 
     (42 U.S.C. 1395m(a)(16)) is amended, in the second sentence, 
     by inserting ``and shall waive such requirement in the case 
     of a pharmacist'' before the period at the end.

     SEC. 515. GAO STUDY AND REPORT ON EFFECTIVENESS OF SURETY 
                   BOND REQUIREMENTS FOR SUPPLIERS OF DURABLE 
                   MEDICAL EQUIPMENT IN COMBATING FRAUD.

       (a) Study.--The Comptroller General of the United States 
     shall conduct a study on the effectiveness of the surety bond 
     requirement under section 1834(a)(16) of the Social Security 
     Act (42 U.S.C. 1395m(a)(16)) in combating fraud.
       (b) Report.--Not later than 1 year after the date of 
     enactment of this Act, the Comptroller General shall submit 
     to Congress a report containing the results of the study 
     conducted under subsection (a), together with recommendations 
     for such legislation and administrative action as the 
     Comptroller General determines appropriate.

                     TITLE VI--ENDING LAWSUIT ABUSE

     SEC. 601. STATE GRANTS TO CREATE HEALTH COURT SOLUTIONS.

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

     ``SEC. 399R. STATE GRANTS TO CREATE HEALTH COURT SOLUTIONS.

       ``(a) In General.--The Secretary may award grants to States 
     for the development, implementation, and evaluation of 
     alternatives to current tort litigation that comply with this 
     section, for the resolution of disputes concerning injuries 
     allegedly caused by health care providers or health care 
     organizations.
       ``(b) Conditions for Demonstration Grants.--
       ``(1) Application.--To be eligible to receive a grant under 
     this section, a State shall submit to the Secretary an 
     application at such time, in such manner, and containing such 
     information as may be required by the Secretary. A grant 
     shall be awarded under this section on such terms and 
     conditions as the Secretary determines appropriate.
       ``(2) State requirements.--To be eligible to receive a 
     grant under this section, a State shall--

[[Page 32810]]

       ``(A) develop and implement an alternative to current tort 
     litigation for resolving disputes over injuries allegedly 
     caused by health care providers or health care organizations 
     based on one or more of the models described in subsection 
     (d); and
       ``(B) implement policies that provide for a reduction in 
     health care errors through the collection and analysis by 
     organizations that engage in voluntary efforts to improve 
     patient safety and the quality of health care delivery, of 
     patient safety data related to disputes resolved under the 
     alternatives under subparagraph (A).
       ``(3) Demonstration of effectiveness.--To be eligible to 
     receive a grant under subsection (a), a State shall 
     demonstrate how the proposed alternative to be implemented 
     under paragraph (2)(A) will--
       ``(A) make the medical liability system of the State more 
     reliable through the prompt and fair resolution of disputes;
       ``(B) encourage the early disclosure of health care errors;
       ``(C) enhance patient safety; and
       ``(D) maintain access to medical liability insurance.
       ``(4) Sources of compensation.--To be eligible to receive a 
     grant under subsection (a), a State shall identify the 
     sources from, and methods by which, compensation would be 
     paid for medical liability claims resolved under the proposed 
     alternative to current tort litigation implemented under 
     paragraph (2)(A). Funding methods shall, to the extent 
     practicable, provide financial incentives for activities that 
     improve patient safety.
       ``(5) Scope.--
       ``(A) In general.--To be eligible to receive a grant under 
     subsection (a), a State shall utilize the proposed 
     alternative identified under paragraph (2)(A) for the 
     resolution of all types of disputes concerning injuries 
     allegedly caused by health care providers or health care 
     organizations.
       ``(B) Current state efforts to establish alternative to 
     tort litigation.--
       ``(i) In general.--Nothing in this section shall be 
     construed to limit the efforts that any State has made prior 
     to the date of enactment of this section to establish any 
     alternative to tort litigation.
       ``(ii) Alternative for practice areas or injuries.--In the 
     case of a State that has established an alternative to tort 
     litigation for a certain area of health care practice or a 
     category of injuries, the alternative selected as provided 
     for in this section shall supplement not replace or 
     invalidate such established alternative unless the State 
     intends otherwise.
       ``(6) Notification of patients.--To be eligible to receive 
     a grant under subsection (a), the State shall demonstrate how 
     patients will be notified when they are receiving health care 
     services that fall within the scope of the alternative 
     selected under this section by the State to current tort 
     litigation.
       ``(c) Representation by Counsel.--A State that receives a 
     grant under this section may not preclude any party to a 
     dispute that falls within the jurisdiction of the alternative 
     to current tort litigation that is implemented under the 
     grant from obtaining legal representation at any point during 
     the consideration of the claim under such alternative.
       ``(d) Models.--
       ``(1) In general.--The models in this section are the 
     following:
       ``(2) Expert panel review and early offer guidelines.--
       ``(A) In general.--A State may use amounts received under a 
     grant under this section to develop and implement an expert 
     panel and early offer review system that meets the 
     requirements of this paragraph.
       ``(B) Establishment of panel.--Under the system under this 
     paragraph, the State shall establish an expert panel to 
     review any disputes concerning injuries allegedly caused by 
     health care providers or health care organizations according 
     to the guidelines described in this paragraph.
       ``(C) Composition.--
       ``(i) In general.--An expert panel under this paragraph 
     shall be composed of 3 medical experts (either physicians or 
     health care professionals) and 3 attorneys to be appointed by 
     the head of the State agency responsible for health.
       ``(ii) Licensure and expertise.--Each physician or health 
     care professional appointed to an expert panel under clause 
     (i) shall--

       ``(I) be appropriately credentialed or licensed in the 
     State in which the dispute takes place to deliver health care 
     services; and
       ``(II) typically treat the condition, make the diagnosis, 
     or provide the type of treatment that is under review.

       ``(iii) Independence.--

       ``(I) In general.--Subject to subclause (II), each 
     individual appointed to an expert panel under this paragraph 
     shall--

       ``(aa) not have a material familial, financial, or 
     professional relationship with a party involved in the 
     dispute reviewed by the panel; and
       ``(bb) not otherwise have a conflict of interest with such 
     a party.

       ``(II) Exception.--Nothing in subclause (I) shall be 
     construed to prohibit an individual who has staff privileges 
     at an institution where the treatment involved in the dispute 
     was provided from serving as a member of an expert panel 
     merely on the basis of such affiliation, if the affiliation 
     is disclosed to the parties and neither party objects.

       ``(iv) Practicing health care professional in same field.--

       ``(I) In general.--In a dispute before an expert panel that 
     involves treatment, or the provision of items or services--

       ``(aa) by a physician, the medical experts on the expert 
     panel shall be practicing physicians (allopathic or 
     osteopathic) of the same or similar specialty as a physician 
     who typically treats the condition, makes the diagnosis, or 
     provides the type of treatment under review; or
       ``(bb) by a health care professional other than a 
     physician, at least two medical experts on the expert panel 
     shall be practicing physicians (allopathic or osteopathic) of 
     the same or similar specialty as the health care professional 
     who typically treats the condition, makes the diagnosis, or 
     provides the type of treatment under review, and, if 
     determined appropriate by the State agency, the third medical 
     expert shall be a practicing health care professional (other 
     than such a physician) of such a same or similar specialty.

       ``(II) Practicing defined.--In this paragraph, the term 
     `practicing' means, with respect to an individual who is a 
     physician or other health care professional, that the 
     individual provides health care services to individual 
     patients on average at least 2 days a week.

       ``(v) Pediatric expertise.--In the case of dispute relating 
     to a child, at least 1 medical expert on the expert panel 
     shall have expertise described in clause (iv)(I) in 
     pediatrics.
       ``(D) Determination.--After a review, an expert panel shall 
     make a determination as to the liability of the parties 
     involved and compensation based on a schedule of compensation 
     that is developed by the panel. Such a schedule shall at 
     least include--
       ``(i) payment for the net economic loss incurred by the 
     patient, on a periodic basis, reduced by any payments 
     received by the patient under--

       ``(I) any health or accident insurance;
       ``(II) any wage or salary continuation plan; or
       ``(III) any disability income insurance;

       ``(ii) payment for the non-economic damages incurred by the 
     patient, if appropriate for the injury, based on a defined 
     payment schedule developed by the State, in consultation with 
     relevant experts and with the Secretary;
       ``(iii) reasonable attorney's fees; and
       ``(iv) regular updates of the schedule under clause (ii) as 
     necessary.
       ``(E) Acceptance.--If the parties to a dispute who come 
     before an expert panel under this paragraph accept the 
     determination of the expert panel concerning liability and 
     compensation, such compensation shall be paid to the claimant 
     and the claimant shall agree to forgo any further action 
     against the health care providers or health care 
     organizations involved.
       ``(F) Failure to accept.--If any party decides not to 
     accept the expert panel's determination under this paragraph, 
     the State may choose whether to allow the panel to review the 
     determination de novo, with deference, or to provide an 
     opportunity for parties to reject the determination of the 
     panel.
       ``(G) Review by state court after exhaustion of 
     administrative remedies.--
       ``(i) Right to file.--If the State elects not to permit the 
     expert panel under this paragraph to conduct its own reviews 
     of determinations, or if the State elects to permit such 
     reviews but a party is not satisfied with the final decision 
     of the panel after such a review, the party shall have the 
     right to file a claim relating to the injury involved in a 
     State court of competent jurisdiction.
       ``(ii) Forfeit of awards.--Any party filing an action in a 
     State court under clause (i) shall forfeit any compensation 
     award made under subparagraph (C).
       ``(iii) Admissibility.--The determinations of the expert 
     panel pursuant to a review under subparagraph (C) shall be 
     admissible into evidence in any State court proceeding under 
     this subparagraph.
       ``(3) Administrative health care tribunals.--
       ``(A) In general.--A State may use amounts received under a 
     grant under this section to develop and implement an 
     administrative health care tribunal system under which the 
     parties involved shall have the right to request a hearing to 
     review any dispute concerning injuries allegedly caused by 
     health care providers or health care organizations before an 
     administrative health care tribunal established by the State 
     involved.
       ``(B) Requirements.--In establishing an administrative 
     health care tribunal under this paragraph, a State shall--
       ``(i) ensure that such tribunals are presided over by 
     special judges with health care expertise who meet applicable 
     State standards for judges and who agree to preside over such 
     court voluntarily;
       ``(ii) provide authority to such judges to make binding 
     rulings, rendered in written decisions, on standards of care, 
     causation, compensation, and related issues with reliance on 
     independent expert witnesses commissioned by the tribunal;
       ``(iii) establish a legal standard for the tribunal that 
     shall be the same as the standard

[[Page 32811]]

     that would apply in the State court of competent jurisdiction 
     which would otherwise handle the claim; and
       ``(iv) provide for an appeals process to allow for review 
     of decisions by State courts.
       ``(C) Determination.--After a tribunal conducts a review 
     under this paragraph, the tribunal shall make a determination 
     as to the liability of the parties involved and the amount of 
     compensation that should be paid based on a schedule of 
     compensation developed by the tribunal. Such a schedule shall 
     at a minimum include--
       ``(i) payment for the net economic loss incurred by the 
     patient, on a periodic basis, reduced by any payments 
     received by the patient under--

       ``(I) any health or accident insurance;
       ``(II) any wage or salary continuation plan; or
       ``(III) any disability income insurance;

       ``(ii) payment for the non-economic damages incurred by the 
     patient, if appropriate for the injury, based on a defined 
     payment schedule developed by the State in consultation with 
     relevant experts and with the Secretary;
       ``(iii) reasonable attorney's fees; and
       ``(iv) regular updates of the schedule under clause (ii) as 
     necessary.
       ``(D) Review by state court after exhaustion of 
     administrative remedies.--
       ``(i) Right to file.--Nothing in this paragraph shall be 
     construed to prohibit any individual who is not satisfied 
     with the determinations of a tribunal under this paragraph, 
     from filing a claim for the injury involved in a State court 
     of competent jurisdiction.
       ``(ii) Forfeit of award.--Any party filing an action in a 
     State court under clause (i) shall forfeit any compensation 
     award made under subparagraph (C).
       ``(iii) Admissibility.--The determinations of the tribunal 
     under subparagraph (C) shall be admissible into evidence in 
     any State court proceeding under this subparagraph.
       ``(4) Expert panel review and administrative health care 
     tribunal combination model.--
       ``(A) In general.--A State may use amounts received under a 
     grant under this section to develop and implement an expert 
     panel review and administrative health care tribunal 
     combination system to review any dispute concerning injuries 
     allegedly caused by health care providers or health care 
     organizations. Under such system, a dispute concerning 
     injuries allegedly caused by health care providers or health 
     care organizations shall proceed through the procedures 
     described in this subparagraph prior to the submission of 
     such dispute to a State court.
       ``(B) General procedure.--
       ``(i) Establishment of expert panel.--Prior to submitting 
     any dispute described in subparagraph (A) to an 
     administrative health care tribunal under the system 
     established under this paragraph, the State shall establish 
     an expert panel (in accordance with subparagraph (C)) to 
     review the allegations involved in such dispute.
       ``(ii) Referral to tribunal.--If either party to a dispute 
     described in clause (i) fails to accept the determination of 
     the expert panel, the dispute shall then be referred to an 
     administrative health care tribunal (in accordance with 
     subparagraph (D).
       ``(C) Expert review panel.--
       ``(i) In general.--The provisions of paragraph (2) shall 
     apply with respect to the establishment and operation of an 
     expert review panel under this subparagraph, except that the 
     subparagraphs (F) and (G) of such paragraph shall not apply.
       ``(ii) Failure to accept determination of panel.--If any 
     party to a dispute before an expert panel under this 
     subparagraph refuses to accept the panel's determination, the 
     dispute shall be referred to an administrative health care 
     tribunal under subparagraph (D).
       ``(D) Administrative health care tribunals.--
       ``(i) In general.--Upon the failure of any party to accept 
     the determination of an expert panel under subparagraph (C), 
     the parties shall request a hearing concerning the liability 
     or compensation involved by an administrative health care 
     tribunal established by the State involved under this 
     subparagraph.
       ``(ii) Requirements.--The provisions of paragraph (3) shall 
     apply with respect to the establishment and operation of an 
     administrative health care tribunal under this subparagraph.
       ``(iii) Forfeit of awards.--Any party proceeding to the 
     second step-administrative health care tribunal-under this 
     model shall forfeit any compensation awarded by the expert 
     panel.
       ``(iv) Admissibility.--The determinations of the expert 
     panel under subparagraph (C) shall be admissible into 
     evidence in any administrative health care tribunal 
     proceeding under this subparagraph.
       ``(E) Right to file.--Nothing in this paragraph shall be 
     construed to prohibit any individual who is not satisfied 
     with the determination of the tribunal (after having 
     proceeded through both the expert panel under subparagraph 
     (C) and the tribunal under subparagraph (D)) from filing a 
     claim for the injury involved in a State court of competent 
     jurisdiction.
       ``(F) Admissibility.--The determinations of both the expert 
     panel and the tribunal under this paragraph shall be 
     admissible into evidence in any State court proceeding under 
     this paragraph.
       ``(G) Forfeit of awards.--Any party filing an action in 
     State court under subparagraph (E) shall forfeit any 
     compensation award made by both the expert panel and the 
     administrative health care tribunal under this paragraph.
       ``(e) Definitions.--In this section:
       ``(1) Current tort litigation.--The term `current tort 
     litigation' means the tort litigation system existing in the 
     State on the date on which the State submits an application 
     under subsection (b)(1), for the resolution of disputes 
     concerning injuries allegedly caused by health care providers 
     or health care organizations.
       ``(2) Health care organization.--The term `health care 
     organization' means any individual or entity that is 
     obligated to provide, pay for, or administer health benefits 
     under any health plan.
       ``(3) Net economic loss.--The term `net economic loss' 
     means--
       ``(A) reasonable expenses incurred for products, services 
     and accommodations needed for health care, training and other 
     remedial treatment and care of an injured individual;
       ``(B) reasonable and appropriate expenses for 
     rehabilitation treatment and occupational training;
       ``(C) 100 percent of the loss of income from work that an 
     injured individual would have performed if not injured, 
     reduced by any income from substitute work actually 
     performed; and
       ``(D) reasonable expenses incurred in obtaining ordinary 
     and necessary services to replace services an injured 
     individual would have performed for the benefit of the 
     individual or the family of such individual if the individual 
     had not been injured.
       ``(4) Non-economic damages.--The term `non-economic 
     damages' means losses for physical and emotional pain, 
     suffering, inconvenience, physical impairment, mental 
     anguish, disfigurement, loss of enjoyment of life, loss of 
     society and companionship, loss of consortium (other than 
     loss of domestic service), injury to reputation, and all 
     other non-pecuniary losses of any kind or nature, to the 
     extent permitted under State law.
       ``(f) Funding.--
       ``(1) One-time increase in medicaid payment.--In the case 
     of a State awarded a grant to carry out this section, the 
     total amount of the Federal payment determined for the State 
     under section 1913 of the Social Security Act (as amended by 
     section 401) for fiscal year 2011 (in addition to the any 
     increase applicable for that fiscal year under section 203(b) 
     but determined without regard to any such increase) shall be 
     increased by an amount equal to 1 percent of the total amount 
     of payments made to the State for fiscal year 2010 under 
     section 1903(a) of the Social Security Act (42 U.S.C. 
     1396b(a)) for purposes of carrying out a grant awarded under 
     this section. Amounts paid to a State pursuant to this 
     subsection shall remain available until expended.
       ``(2) Authorization of appropriations.--There are 
     authorized to be appropriated for any fiscal year such sums 
     as may be necessary for purposes of making payments to States 
     pursuant to paragraph (1).''.

           TITLE VII--PROMOTING HEALTH INFORMATION TECHNOLOGY

 Subtitle A--Assisting the Development of Health Information Technology

     SEC. 701. PURPOSE.

       It is the purpose of this subtitle to promote the 
     utilization of health record banking by improving the 
     coordination of health information through an infrastructure 
     for the secure and authorized exchange and use of healthcare 
     information.

     SEC. 702. HEALTH RECORD BANKING.

       (a) Establishment.--Not later than 1 year after the date of 
     enactment of this Act, the Secretary of Health and Human 
     Services shall promulgate regulations to provide for the 
     certification and auditing of the banking of electronic 
     medical records.
       (b) General Rights.--An individual who has a health record 
     contained in a health record bank shall maintain ownership 
     over the health record and shall have the right to review the 
     contents of the record.

     SEC. 703. APPLICATION OF FEDERAL AND STATE SECURITY AND 
                   CONFIDENTIALITY STANDARDS.

       (a) In General.--Current Federal security and 
     confidentiality standards and State security and 
     confidentiality laws shall apply to this subtitle until such 
     time as Congress acts to amend such standards.
       (b) Definitions.--In this section:
       (1) Current federal security and confidentiality 
     standards.--The term ``current Federal security and 
     confidentiality standards'' means the Federal privacy 
     standards established pursuant to section 264(c) of the 
     Health Insurance Portability and Accountability Act of 1996 
     (42 U.S.C. 1320d-2 note) and security standards established 
     under section 1173(d) of the Social Security Act (42 U.S.C. 
     1320d-2(d)).
       (2) State security and confidentiality laws.--The term 
     ``State security and confidentiality laws'' means State laws 
     and regulations relating to the privacy and confidentiality 
     of individually identifiable health information or to the 
     security of such information.

[[Page 32812]]

       (3) State.--The term ``State'' has the meaning given such 
     term for purposes of title XI of the Social Security Act, as 
     provided under section 1101(a) of such Act (42 U.S.C. 
     1301(a)).

    Subtitle B--Removing Barriers to the Use of Health Information 
              Technology to Better Coordinate Health Care

     SEC. 711. SAFE HARBORS TO ANTIKICKBACK CIVIL PENALTIES AND 
                   CRIMINAL PENALTIES FOR PROVISION OF HEALTH 
                   INFORMATION TECHNOLOGY AND TRAINING SERVICES.

       (a) For Civil Penalties.--Section 1128A of the Social 
     Security Act (42 U.S.C. 1320a-7a) is amended--
       (1) in subsection (b), by adding at the end the following 
     new paragraph:
       ``(4) For purposes of this subsection, inducements to 
     reduce or limit services described in paragraph (1) shall not 
     include the practical or other advantages resulting from 
     health information technology or related installation, 
     maintenance, support, or training services.''; and
       (2) in subsection (i), by adding at the end the following 
     new paragraph:
       ``(8) The term `health information technology' means 
     hardware, software, license, right, intellectual property, 
     equipment, or other information technology (including new 
     versions, upgrades, and connectivity) designed or provided 
     primarily for the electronic creation, maintenance, or 
     exchange of health information to better coordinate care or 
     improve health care quality, efficiency, or research.''.
       (b) For Criminal Penalties.--Section 1128B of such Act (42 
     U.S.C. 1320a-7b) is amended--
       (1) in subsection (b)(3)--
       (A) in subparagraph (G), by striking ``and'' at the end;
       (B) in the subparagraph (H) added by section 237(d) of the 
     Medicare Prescription Drug, Improvement, and Modernization 
     Act of 2003 (Public Law 108-173; 117 Stat. 2213)--
       (i) by moving such subparagraph 2 ems to the left; and
       (ii) by striking the period at the end and inserting a 
     semicolon;
       (C) in the subparagraph (H) added by section 431(a) of such 
     Act (117 Stat. 2287)--
       (i) by redesignating such subparagraph as subparagraph (I);
       (ii) by moving such subparagraph 2 ems to the left; and
       (iii) by striking the period at the end and inserting ``; 
     and''; and
       (D) by adding at the end the following new subparagraph:
       ``(J) any nonmonetary remuneration (in the form of health 
     information technology, as defined in section 1128A(i)(8), or 
     related installation, maintenance, support or training 
     services) made to a person by a specified entity (as defined 
     in subsection (g)) if--
       ``(i) the provision of such remuneration is without an 
     agreement between the parties or legal condition that--
       ``(I) limits or restricts the use of the health information 
     technology to services provided by the physician to 
     individuals receiving services at the specified entity;
       ``(II) limits or restricts the use of the health 
     information technology in conjunction with other health 
     information technology; or
       ``(III) conditions the provision of such remuneration on 
     the referral of patients or business to the specified entity;
       ``(ii) such remuneration is arranged for in a written 
     agreement that is signed by the parties involved (or their 
     representatives) and that specifies the remuneration 
     solicited or received (or offered or paid) and states that 
     the provision of such remuneration is made for the primary 
     purpose of better coordination of care or improvement of 
     health quality, efficiency, or research; and
       ``(iii) the specified entity providing the remuneration (or 
     a representative of such entity) has not taken any action to 
     disable any basic feature of any hardware or software 
     component of such remuneration that would permit 
     interoperability.''; and
       (2) by adding at the end the following new subsection:
       ``(g) Specified Entity Defined.--For purposes of subsection 
     (b)(3)(J), the term `specified entity' means an entity that 
     is a hospital, group practice, prescription drug plan 
     sponsor, a Medicare Advantage organization, or any other such 
     entity specified by the Secretary, considering the goals and 
     objectives of this section, as well as the goals to better 
     coordinate the delivery of health care and to promote the 
     adoption and use of health information technology.''.
       (c) Effective Date and Effect on State Laws.--
       (1) Effective date.--The amendments made by subsections (a) 
     and (b) shall take effect on the date that is 120 days after 
     the date of the enactment of this Act.
       (2) Preemption of state laws.--No State (as defined in 
     section 1101(a) of the Social Security Act (42 U.S.C. 
     1301(a)) for purposes of title XI of such Act) shall have in 
     effect a State law that imposes a criminal or civil penalty 
     for a transaction described in section 1128A(b)(4) or section 
     1128B(b)(3)(J) of such Act, as added by subsections (a)(1) 
     and (b), respectively, if the conditions described in the 
     respective provision, with respect to such transaction, are 
     met.
       (d) Study and Report To Assess Effect of Safe Harbors on 
     Health System.--
       (1) In general.--The Secretary of Health and Human Services 
     shall conduct a study to determine the impact of each of the 
     safe harbors described in paragraph (3). In particular, the 
     study shall examine the following:
       (A) The effectiveness of each safe harbor in increasing the 
     adoption of health information technology.
       (B) The types of health information technology provided 
     under each safe harbor.
       (C) The extent to which the financial or other business 
     relationships between providers under each safe harbor have 
     changed as a result of the safe harbor in a way that 
     adversely affects or benefits the health care system or 
     choices available to consumers.
       (D) The impact of the adoption of health information 
     technology on health care quality, cost, and access under 
     each safe harbor.
       (2) Report.--Not later than 3 years after the effective 
     date described in subsection (c)(1), the Secretary of Health 
     and Human Services shall submit to Congress a report on the 
     study under paragraph (1).
       (3) Safe harbors described.--For purposes of paragraphs (1) 
     and (2), the safe harbors described in this paragraph are--
       (A) the safe harbor under section 1128A(b)(4) of such Act 
     (42 U.S.C. 1320a-7a(b)(4)), as added by subsection (a)(1); 
     and
       (B) the safe harbor under section 1128B(b)(3)(J) of such 
     Act (42 U.S.C. 1320a-7b(b)(3)(J)), as added by subsection 
     (b).

     SEC. 712. EXCEPTION TO LIMITATION ON CERTAIN PHYSICIAN 
                   REFERRALS (UNDER STARK) FOR PROVISION OF HEALTH 
                   INFORMATION TECHNOLOGY AND TRAINING SERVICES TO 
                   HEALTH CARE PROFESSIONALS.

       (a) In General.--Section 1877(b) of the Social Security Act 
     (42 U.S.C. 1395nn(b)) is amended by adding at the end the 
     following new paragraph:
       ``(6) Information technology and training services.--
       ``(A) In general.--Any nonmonetary remuneration (in the 
     form of health information technology or related 
     installation, maintenance, support or training services) made 
     by a specified entity to a physician if--
       ``(i) the provision of such remuneration is without an 
     agreement between the parties or legal condition that--

       ``(I) limits or restricts the use of the health information 
     technology to services provided by the physician to 
     individuals receiving services at the specified entity;
       ``(II) limits or restricts the use of the health 
     information technology in conjunction with other health 
     information technology; or
       ``(III) conditions the provision of such remuneration on 
     the referral of patients or business to the specified entity;

       ``(ii) such remuneration is arranged for in a written 
     agreement that is signed by the parties involved (or their 
     representatives) and that specifies the remuneration made and 
     states that the provision of such remuneration is made for 
     the primary purpose of better coordination of care or 
     improvement of health quality, efficiency, or research; and
       ``(iii) the specified entity (or a representative of such 
     entity) has not taken any action to disable any basic feature 
     of any hardware or software component of such remuneration 
     that would permit interoperability.
       ``(B) Health information technology defined.--For purposes 
     of this paragraph, the term `health information technology' 
     means hardware, software, license, right, intellectual 
     property, equipment, or other information technology 
     (including new versions, upgrades, and connectivity) designed 
     or provided primarily for the electronic creation, 
     maintenance, or exchange of health information to better 
     coordinate care or improve health care quality, efficiency, 
     or research.
       ``(C) Specified entity defined.--For purposes of this 
     paragraph, the term `specified entity' means an entity that 
     is a hospital, group practice, prescription drug plan 
     sponsor, a Medicare Advantage organization, or any other such 
     entity specified by the Secretary, considering the goals and 
     objectives of this section, as well as the goals to better 
     coordinate the delivery of health care and to promote the 
     adoption and use of health information technology.''.
       (b) Effective Date; Effect on State Laws.--
       (1) Effective date.--The amendment made by subsection (a) 
     shall take effect on the date that is 120 days after the date 
     of the enactment of this Act.
       (2) Preemption of state laws.--No State (as defined in 
     section 1101(a) of the Social Security Act (42 U.S.C. 
     1301(a)) for purposes of title XI of such Act) shall have in 
     effect a State law that imposes a criminal or civil penalty 
     for a transaction described in section 1877(b)(6) of such 
     Act, as added by subsection (a), if the conditions described 
     in such section, with respect to such transaction, are met.
       (c) Study and Report To Assess Effect of Exception on 
     Health System.--
       (1) In general.--The Secretary of Health and Human Services 
     shall conduct a study to determine the impact of the 
     exception under section 1877(b)(6) of such Act (42 U.S.C. 
     1395nn(b)(6)), as added by subsection (a). In particular, the 
     study shall examine the following:

[[Page 32813]]

       (A) The effectiveness of the exception in increasing the 
     adoption of health information technology.
       (B) The types of health information technology provided 
     under the exception.
       (C) The extent to which the financial or other business 
     relationships between providers under the exception have 
     changed as a result of the exception in a way that adversely 
     affects or benefits the health care system or choices 
     available to consumers.
       (D) The impact of the adoption of health information 
     technology on health care quality, cost, and access under the 
     exception.
       (2) Report.--Not later than 3 years after the effective 
     date described in subsection (b)(1), the Secretary of Health 
     and Human Services shall submit to Congress a report on the 
     study under paragraph (1).

     SEC. 713. RULES OF CONSTRUCTION REGARDING USE OF CONSORTIA.

       (a) Application to Safe Harbor From Criminal Penalties.--
     Section 1128B(b)(3) of the Social Security Act (42 U.S.C. 
     1320a-7b(b)(3)) is amended by adding after and below 
     subparagraph (J), as added by section 711(b)(1), the 
     following: ``For purposes of subparagraph (J), nothing in 
     such subparagraph shall be construed as preventing a 
     specified entity, consistent with the specific requirements 
     of such subparagraph, from forming a consortium composed of 
     health care providers, payers, employers, and other 
     interested entities to collectively purchase and donate 
     health information technology, or from offering health care 
     providers a choice of health information technology products 
     in order to take into account the varying needs of such 
     providers receiving such products.''.
       (b) Application to Stark Exception.--Paragraph (6) of 
     section 1877(b) of the Social Security Act (42 U.S.C. 
     1395nn(b)), as added by section 712(a), is amended by adding 
     at the end the following new subparagraph:
       ``(D) Rule of construction.--For purposes of subparagraph 
     (A), nothing in such subparagraph shall be construed as 
     preventing a specified entity, consistent with the specific 
     requirements of such subparagraph, from--
       ``(i) forming a consortium composed of health care 
     providers, payers, employers, and other interested entities 
     to collectively purchase and donate health information 
     technology; or
       ``(ii) offering health care providers a choice of health 
     information technology products in order to take into account 
     the varying needs of such providers receiving such 
     products.''.

              TITLE VIII--HEALTH CARE SERVICES COMMISSION

              Subtitle A--Establishment and General Duties

     SEC. 801. ESTABLISHMENT.

       (a) In General.--There is hereby established a Health Care 
     Services Commission (in this title, referred to as the 
     ``Commission'') to be composed of 5 commissioners (in this 
     title referred to as the ``Commissioners'') to be appointed 
     by the President by and with the advice and consent of the 
     Senate. Not more than 3 of such Commissioners shall be 
     members of the same political party, and in making 
     appointments members of different political parties shall be 
     appointed alternately as nearly as may be practicable. No 
     Commissioner shall engage in any other business, vocation, or 
     employment than that of serving as Commissioner. Each 
     Commissioner shall hold office for a term of 5 years and 
     until a successor is appointed and has qualified, except 
     that--
       (1) such Commissioner shall not so continue to serve beyond 
     the expiration of the next session of Congress subsequent to 
     the expiration of said fixed term of office;
       (2) any Commissioner appointed to fill a vacancy occurring 
     prior to the expiration of the term for which a predecessor 
     was appointed shall be appointed for the remainder of such 
     term; and
       (3) the terms of office of the Commissioners first taking 
     office after the date of the enactment of this Act shall 
     expire as designated by the President at the time of 
     nomination, 1 at the end of 1 year, 1 at the end of 2 years, 
     1 at the end of 3 years, 1 at the end of 4 years, and 1 at 
     the end of 5 years, after the date of the enactment of this 
     Act.
       (b) Purpose.--The purpose of the Commission is to enhance 
     the quality, appropriateness, and effectiveness of health 
     care services, and access to such services, through the 
     establishment of a broad base of scientific research and 
     through the promotion of improvements in clinical practice 
     and in the organization, financing, and delivery of health 
     care services.
       (c) Appointment of Chairman.--The President shall, from 
     among the Commissioners appointed under subsection (a), 
     designate an individual to serve as the Chairman of the 
     Commission.

     SEC. 802. GENERAL AUTHORITIES AND DUTIES.

       (a) In General.--In carrying out section 801(b), the 
     Commissioners shall conduct and support research, 
     demonstration projects, evaluations, training, guideline 
     development, and the dissemination of information, on health 
     care services and on systems for the delivery of such 
     services, including activities with respect to--
       (1) the effectiveness, efficiency, and quality of health 
     care services;
       (2) the outcomes of health care services and procedures;
       (3) clinical practice, including primary care and practice-
     oriented research;
       (4) health care technologies, facilities, and equipment;
       (5) health care costs, productivity, and market forces;
       (6) health promotion and disease prevention;
       (7) health statistics and epidemiology; and
       (8) medical liability.
       (b) Requirements With Respect to Rural Areas and 
     Underserved Populations.--In carrying out subsection (a), the 
     Commissioners shall undertake and support research, 
     demonstration projects, and evaluations with respect to--
       (1) the delivery of health care services in rural areas 
     (including frontier areas); and
       (2) the health of low-income groups, minority groups, and 
     the elderly.

     SEC. 803. DISSEMINATION.

       (a) In General.--The Commissioners shall--
       (1) promptly publish, make available, and otherwise 
     disseminate, in a form understandable and on as broad a basis 
     as practicable so as to maximize its use, the results of 
     research, demonstration projects, and evaluations conducted 
     or supported under this title and the guidelines, standards, 
     and review criteria developed under this title;
       (2) promptly make available to the public data developed in 
     such research, demonstration projects, and evaluations; and
       (3) as appropriate, provide technical assistance to State 
     and local government and health agencies and conduct liaison 
     activities to such agencies to foster dissemination.
       (b) Prohibition Against Restrictions.--Except as provided 
     in subsection (c), the Commissioners may not restrict the 
     publication or dissemination of data from, or the results of, 
     projects conducted or supported under this title.
       (c) Limitation on Use of Certain Information.--No 
     information, if an establishment or person supplying the 
     information or described in it is identifiable, obtained in 
     the course of activities undertaken or supported under this 
     title may be used for any purpose other than the purpose for 
     which it was supplied unless such establishment or person has 
     consented (as determined under regulations of the Secretary) 
     to its use for such other purpose. Such information may not 
     be published or released in other form if the person who 
     supplied the information or who is described in it is 
     identifiable unless such person has consented (as determined 
     under regulations of the Secretary) to its publication or 
     release in other form.
       (d) Certain Interagency Agreement.--The Commissioners and 
     the Director of the National Library of Medicine shall enter 
     into an agreement providing for the implementation of 
     subsection (a)(1).

     Subtitle B--Forum for Quality and Effectiveness in Health Care

     SEC. 811. ESTABLISHMENT OF OFFICE.

       There is established within the Commission an office to be 
     known as the Office of the Forum for Quality and 
     Effectiveness in Health Care. The office shall be headed by a 
     director (referred to in this title as the ``Director'') who 
     shall be appointed by the Commissioners.

     SEC. 812. MEMBERSHIP.

       (a) In General.--The Office of the Forum for Quality and 
     Effectiveness in Health Care shall be composed of 15 
     individuals nominated by private sector health care 
     organizations and appointed by the Commission and shall 
     include representation from at least the following:
       (1) Health insurance industry.
       (2) Health care provider groups.
       (3) Non-profit organizations.
       (4) Rural health organizations.
       (b) Terms.--
       (1) In general.--Except as provided in paragraph (2), 
     members of the Office of the Forum for Quality and 
     Effectiveness in Health Care shall serve for a term of 5 
     years.
       (2) Staggered rotation.--Of the members first appointed to 
     the Office of the Forum for Quality and Effectiveness in 
     Health Care, the Commission shall appoint 5 members to serve 
     for a term of 2 years, 5 members to serve for a term of 3 
     years, and 5 members to serve for a term of 4 years.
       (c) Treatment of Other Employment.--Each member of the 
     Office of the Forum for Quality and Effectiveness in Health 
     Care shall serve the Office independently from any other 
     position of employment.

     SEC. 813. DUTIES.

       (a) Establishment of Forum Program.--The Commissioners, 
     acting through the Director, shall establish a program to be 
     known as the Forum for Quality and Effectiveness in Health 
     Care. For the purpose of promoting transparency in price, 
     quality, appropriateness, and effectiveness of health care, 
     the Director, using the process set forth in section 814, 
     shall arrange for the development and periodic review and 
     updating of standards of quality, performance measures, and 
     medical review criteria through which health care providers 
     and other appropriate entities may assess or review the 
     provision of health care and assure the quality of such care.
       (b) Certain Requirements.--Guidelines, standards, 
     performance measures, and review criteria under subsection 
     (a) shall--

[[Page 32814]]

       (1) be based on the best available research and 
     professional judgment regarding the effectiveness and 
     appropriateness of health care services and procedures; and
       (2) be presented in formats appropriate for use by 
     physicians, health care practitioners, providers, medical 
     educators, and medical review organizations and in formats 
     appropriate for use by consumers of health care.
       (c) Authority for Contracts.--In carrying out this 
     subtitle, the Director may enter into contracts with public 
     or nonprofit private entities.
       (d) Public Disclosure of Recommendations.--For each fiscal 
     year beginning with 2010, the Director shall make publicly 
     available the following:
       (1) Quarterly reports for public comment that include 
     proposed recommendations for guidelines, standards, 
     performance measures, and review criteria under subsection 
     (a) and any updates to such guidelines, standards, 
     performance measures, and review criteria.
       (2) After consideration of such comments, a final report 
     that contains final recommendations for such guidelines, 
     standards, performance measures, review criteria, and 
     updates.
       (e) Date Certain for Initial Guidelines and Standards.--The 
     Commissioners, by not later than January 1, 2012, shall 
     assure the development of an initial set of guidelines, 
     standards, performance measures, and review criteria under 
     subsection (a).

     SEC. 814. ADOPTION AND ENFORCEMENT OF GUIDELINES AND 
                   STANDARDS.

       (a) Adoption of Recommendations of Forum for Quality and 
     Effectiveness in Health Care.--For each fiscal year, the 
     Commissioners shall adopt the recommendations made for such 
     year in the final report under subsection (d)(2) of section 
     813 for guidelines, standards, performance measures, and 
     review criteria described in subsection (a) of such section.
       (b) Enforcement Authority.--The Commissioners, in 
     consultation with the Secretary of Health and Human Services, 
     have the authority to make recommendations to the Secretary 
     to enforce compliance of health care providers with the 
     guidelines, standards, performance measures, and review 
     criteria adopted under subsection (a). Such recommendations 
     may include the following, with respect to a health care 
     provider who is not in compliance with such guidelines, 
     standards, measures, and criteria:
       (1) Exclusion from participation in Federal health care 
     programs (as defined in section 1128B(f) of the Social 
     Security Act (42 U.S.C. 1320a-7b(f))).
       (2) Imposition of a civil money penalty on such provider.

     SEC. 815. ADDITIONAL REQUIREMENTS.

       (a) Program Agenda.--The Commissioners shall provide for an 
     agenda for the development of the guidelines, standards, 
     performance measures, and review criteria described in 
     section 813(a), including with respect to the standards, 
     performance measures, and review criteria, identifying 
     specific aspects of health care for which the standards, 
     performance measures, and review criteria are to be developed 
     and those that are to be given priority in the development of 
     the standards, performance measures, and review criteria.

                     Subtitle C--General Provisions

     SEC. 821. CERTAIN ADMINISTRATIVE AUTHORITIES.

       The Commissioners, in carrying out this title, may accept 
     voluntary and uncompensated services.

     SEC. 822. FUNDING.

       For the purpose of carrying out this title, there are 
     authorized to be appropriated such sums as may be necessary 
     for fiscal years 2010 through 2014.

     SEC. 823. DEFINITIONS.

       For purposes of this title:
       (1) The term ``Commissioners'' means the Commissioners of 
     the Health Care Services Commission.
       (2) The term ``Commission'' means the Health Care Services 
     Commission.
       (3) The term ``Director'' means the Director of the Office 
     of the Forum for Quality and Effectiveness in Health Care.
       (4) The term ``Secretary'' means the Secretary of Health 
     and Human Services.

                Subtitle D--Terminations and Transition

     SEC. 831. TERMINATION OF AGENCY FOR HEALTHCARE RESEARCH AND 
                   QUALITY.

       As of the date of the enactment of this Act, the Agency for 
     Healthcare Research and Quality is terminated, and title IX 
     of the Public Health Service Act is repealed.

     SEC. 832. TRANSITION.

       All orders, grants, contracts, privileges, and other 
     determinations or actions of the Agency for Healthcare 
     Research and Quality that are effective as of the date before 
     the date of the enactment of this Act, shall be transferred 
     to the Secretary and shall continue in effect according to 
     their terms unless changed pursuant to law.

              Subtitle E--Independent Health Record Trust

     SEC. 841. SHORT TITLE.

       This subtitle may be cited as the ``Independent Health 
     Record Trust Act of 2009''.

     SEC. 842. PURPOSE.

       It is the purpose of this subtitle to provide for the 
     establishment of a nationwide health information technology 
     network that--
       (1) improves health care quality, reduces medical errors, 
     increases the efficiency of care, and advances the delivery 
     of appropriate, evidence-based health care services;
       (2) promotes wellness, disease prevention, and the 
     management of chronic illnesses by increasing the 
     availability and transparency of information related to the 
     health care needs of an individual;
       (3) ensures that appropriate information necessary to make 
     medical decisions is available in a usable form at the time 
     and in the location that the medical service involved is 
     provided;
       (4) produces greater value for health care expenditures by 
     reducing health care costs that result from inefficiency, 
     medical errors, inappropriate care, and incomplete 
     information;
       (5) promotes a more effective marketplace, greater 
     competition, greater systems analysis, increased choice, 
     enhanced quality, and improved outcomes in health care 
     services;
       (6) improves the coordination of information and the 
     provision of such services through an effective 
     infrastructure for the secure and authorized exchange and use 
     of health information; and
       (7) ensures that the health information privacy, security, 
     and confidentiality of individually identifiable health 
     information is protected.

     SEC. 843. DEFINITIONS.

       In this subtitle:
       (1) Access.--The term ``access'' means, with respect to an 
     electronic health record, entering information into such 
     account as well as retrieving information from such account.
       (2) Account.--The term ``account'' means an electronic 
     health record of an individual contained in an independent 
     health record trust.
       (3) Affirmative consent.--The term ``affirmative consent'' 
     means, with respect to an electronic health record of an 
     individual contained in an IHRT, express consent given by the 
     individual for the use of such record in response to a clear 
     and conspicuous request for such consent or at the 
     individual's own initiative.
       (4) Authorized ehr data user.--The term ``authorized EHR 
     data user'' means, with respect to an electronic health 
     record of an IHRT participant contained as part of an IHRT, 
     any entity (other than the participant) authorized (in the 
     form of affirmative consent) by the participant to access the 
     electronic health record.
       (5) Confidentiality.--The term ``confidentiality'' means, 
     with respect to individually identifiable health information 
     of an individual, the obligation of those who receive such 
     information to respect the health information privacy of the 
     individual.
       (6) Electronic health record.--The term ``electronic health 
     record'' means a longitudinal collection of information 
     concerning a single individual, including medical records and 
     personal health information, that is stored electronically.
       (7) Health information privacy.--The term ``health 
     information privacy'' means, with respect to individually 
     identifiable health information of an individual, the right 
     of such individual to control the acquisition, uses, or 
     disclosures of such information.
       (8) Health plan.--The term ``health plan'' means a group 
     health plan (as defined in section 2208(1) of the Public 
     Health Service Act (42 U.S.C. 300bb-8(1))) as well as a plan 
     that offers health insurance coverage in the individual 
     market.
       (9) HIPAA privacy regulations.--The term ``HIPAA privacy 
     regulations'' means the regulations promulgated under section 
     264(c) of the Health Insurance Portability and Accountability 
     Act of 1996 (42 U.S.C. 1320d-2 note).
       (10) Independent health record trust; ihrt.--The terms 
     ``independent health record trust'' and ``IHRT'' mean a legal 
     arrangement under the administration of an IHRT operator that 
     meets the requirements of this subtitle with respect to 
     electronic health records of individuals participating in the 
     trust or IHRT.
       (11) IHRT operator.--The term ``IHRT operator'' means, with 
     respect to an IHRT, the organization that is responsible for 
     the administration and operation of the IHRT in accordance 
     with this subtitle.
       (12) IHRT participant.--The term ``IHRT participant'' 
     means, with respect to an IHRT, an individual who has a 
     participation agreement in effect with respect to the 
     maintenance of the individual's electronic health record by 
     the IHRT.
       (13) Individually identifiable health information.--The 
     term ``individually identifiable health information'' has the 
     meaning given such term in section 1171(6) of the Social 
     Security Act (42 U.S.C. 1320d(6)).
       (14) Security.--The term ``security'' means, with respect 
     to individually identifiable health information of an 
     individual, the physical, technological, or administrative 
     safeguards or tools used to protect such information from 
     unwarranted access or disclosure.

     SEC. 844. ESTABLISHMENT, CERTIFICATION, AND MEMBERSHIP OF 
                   INDEPENDENT HEALTH RECORD TRUSTS.

       (a) Establishment.--Not later than one year after the date 
     of the enactment of this

[[Page 32815]]

     Act, the Federal Trade Commission, in consultation with the 
     National Committee on Vital and Health Statistics, shall 
     prescribe standards for the establishment, certification, 
     operation, and interoperability of IHRTs to carry out the 
     purposes described in section 842 in accordance with the 
     provisions of this subtitle.
       (b) Certification.--
       (1) Certification by ftc.--The Federal Trade Commission 
     shall provide for the certification of IHRTs. No IHRT may be 
     certified unless the IHRT is determined to meet the standards 
     for certification established under subsection (a).
       (2) Decertification.--The Federal Trade Commission shall 
     establish a process for the revocation of certification of an 
     IHRT under this section in the case that the IHRT violates 
     the standards established under subsection (a).
       (c) Membership.--
       (1) In general.--To be eligible to be a participant in an 
     IHRT, an individual shall--
       (A) submit to the IHRT information as required by the IHRT 
     to establish an electronic health record with the IHRT; and
       (B) enter into a privacy protection agreement described in 
     section 846(b)(1) with the IHRT.
     The process to determine eligibility of an individual under 
     this subsection shall allow for the establishment by such 
     individual of an electronic health record as expeditiously as 
     possible if such individual is determined so eligible.
       (2) No limitation on membership.--Nothing in this 
     subsection shall be construed to permit an IHRT to restrict 
     membership, including on the basis of health condition.

     SEC. 845. DUTIES OF IHRT TO IHRT PARTICIPANTS.

       (a) Fiduciary Duty of IHRT; Penalties for Violations of 
     Fiduciary Duty.--
       (1) Fiduciary duty.--With respect to the electronic health 
     record of an IHRT participant maintained by an IHRT, the IHRT 
     shall have a fiduciary duty to act for the benefit and in the 
     interests of such participant and of the IHRT as a whole. 
     Such duty shall include obtaining the affirmative consent of 
     such participant prior to the release of information in such 
     participant's electronic health record in accordance with the 
     requirements of this subtitle.
       (2) Penalties.--If the IHRT knowingly or recklessly 
     breaches the fiduciary duty described in paragraph (1), the 
     IHRT shall be subject to the following penalties:
       (A) Loss of certification of the IHRT.
       (B) A fine that is not in excess of $50,000.
       (C) A term of imprisonment for the individuals involved of 
     not more than 5 years.
       (b) Electronic Health Record Deemed To Be Held in Trust by 
     IHRT.--With respect to an individual, an electronic health 
     record maintained by an IHRT shall be deemed to be held in 
     trust by the IHRT for the benefit of the individual and the 
     IHRT shall have no legal or equitable interest in such 
     electronic health record.

     SEC. 846. AVAILABILITY AND USE OF INFORMATION FROM RECORDS IN 
                   IHRT CONSISTENT WITH PRIVACY PROTECTIONS AND 
                   AGREEMENTS.

       (a) Protected Electronic Health Records Use and Access.--
       (1) General rights regarding uses of information.--
       (A) In general.--With respect to the electronic health 
     record of an IHRT participant maintained by an IHRT, subject 
     to paragraph (2)(C), primary uses and secondary uses 
     (described in subparagraphs (B) and (C), respectively) of 
     information within such record (other than by such 
     participant) shall be permitted only upon the authorization 
     of such use, prior to such use, by such participant.
       (B) Primary uses.--For purposes of subparagraph (A) and 
     with respect to an electronic health record of an individual, 
     a primary use is a use for purposes of the individual's self-
     care or care by health care professionals.
       (C) Secondary uses.--For purposes of subparagraph (B) and 
     with respect to an electronic health record of an individual, 
     a secondary use is any use not described in subparagraph (B) 
     and includes a use for purposes of public health research or 
     other related activities. Additional authorization is 
     required for a secondary use extending beyond the original 
     purpose of the secondary use authorized by the IHRT 
     participant involved. Nothing in this paragraph shall be 
     construed as requiring authorization for every secondary use 
     that is within the authorized original purpose.
       (2) Rules for primary use of records for health care 
     purposes.--With respect to the electronic health record of an 
     IHRT participant (or specified parts of such electronic 
     health record) maintained by an IHRT standards for access to 
     such record shall provide for the following:
       (A) Access by ihrt participants to their electronic health 
     records.--
       (i) Ownership.--The participant maintains ownership over 
     the entire electronic health record (and all portions of such 
     record) and shall have the right to electronically access and 
     review the contents of the entire record (and any portion of 
     such record) at any time, in accordance with this 
     subparagraph.
       (ii) Addition of personal information.--The participant may 
     add personal health information to the health record of that 
     participant, except that such participant shall not alter 
     information that is entered into the electronic health record 
     by any authorized EHR data user. Such participant shall have 
     the right to propose an amendment to information that is 
     entered by an authorized EHR data user pursuant to standards 
     prescribed by the Federal Trade Commission for purposes of 
     amending such information.
       (iii) Identification of information entered by 
     participant.--Any additions or amendments made by the 
     participant to the health record shall be identified and 
     disclosed within such record as being made by such 
     participant.
       (B) Access by entities other than ihrt participant.--
       (i) Authorized access only.--Except as provided under 
     subparagraph (C) and paragraph (4), access to the electronic 
     health record (or any portion of the record)--

       (I) may be made only by authorized EHR data users and only 
     to such portions of the record as specified by the 
     participant; and
       (II) may be limited by the participant for purposes of 
     entering information into such record, retrieving information 
     from such record, or both.

       (ii) Identification of entity that enters information.--Any 
     information that is added by an authorized EHR data user to 
     the health record shall be identified and disclosed within 
     such record as being made by such user.
       (iii) Satisfaction of hipaa privacy regulations.--In the 
     case of a record of a covered entity (as defined for purposes 
     of HIPAA privacy regulations), with respect to an individual, 
     if such individual is an IHRT participant with an independent 
     health record trust and such covered entity is an authorized 
     EHR data user, the requirement under the HIPAA privacy 
     regulations for such entity to provide the record to the 
     participant shall be deemed met if such entity, without 
     charge to the IHRT or the participant--

       (I) forwards to the trust an appropriately formatted 
     electronic copy of the record (and updates to such records) 
     for inclusion in the electronic health record of the 
     participant maintained by the trust;
       (II) enters such record into the electronic health record 
     of the participant so maintained; or
       (III) otherwise makes such record available for electronic 
     access by the IHRT or the individual in a manner that permits 
     such record to be included in the account of the individual 
     contained in the IHRT.

       (iv) Notification of sensitive information.--Any 
     information, with respect to the participant, that is 
     sensitive information, as specified by the Federal Trade 
     Commission, shall not be forwarded or entered by an 
     authorized EHR data user into the electronic health record of 
     the participant maintained by the trust unless the user 
     certifies that the participant has been notified of such 
     information.
       (C) Deemed authorization for access for emergency health 
     care.--
       (i) Findings.--Congress finds that--

       (I) given the size and nature of visits to emergency 
     departments in the United States, readily available health 
     information could make the difference between life and death; 
     and
       (II) because of the case mix and volume of patients 
     treated, emergency departments are well positioned to provide 
     information for public health surveillance, community risk 
     assessment, research, education, training, quality 
     improvement, and other uses.

       (ii) Use of information.--With respect to the electronic 
     health record of an IHRT participant (or specified parts of 
     such electronic health record) maintained by an IHRT, the 
     participant shall be deemed as providing authorization (in 
     the form of affirmative consent) for health care providers to 
     access, in connection with providing emergency care services 
     to the participant, a limited, authenticated information set 
     concerning the participant for emergency response purposes, 
     unless the participant specifies that such information set 
     (or any portion of such information set) may not be so 
     accessed. Such limited information set may include 
     information--

       (I) patient identification data, as determined appropriate 
     by the participant;
       (II) provider identification that includes the use of 
     unique provider identifiers;
       (III) payment information;
       (IV) information related to the individual's vitals, 
     allergies, and medication history;
       (V) information related to existing chronic problems and 
     active clinical conditions of the participant; and
       (VI) information concerning physical examinations, 
     procedures, results, and diagnosis data.

       (3) Rules for secondary uses of records for research and 
     other purposes.--
       (A) In general.--With respect to the electronic health 
     record of an IHRT participant (or specified parts of such 
     electronic health record) maintained by an IHRT, the IHRT may 
     sell such record (or specified parts of such record) only 
     if--
       (i) the transfer is authorized by the participant pursuant 
     to an agreement between the participant and the IHRT and is 
     in accordance with the privacy protection agreement

[[Page 32816]]

     described in subsection (b)(1) entered into between such 
     participant and such IHRT;
       (ii) such agreement includes parameters with respect to the 
     disclosure of information involved and a process for the 
     authorization of the further disclosure of information in 
     such record;
       (iii) the information involved is to be used for research 
     or other activities only as provided for in the agreement;
       (iv) the recipient of the information provides assurances 
     that the information will not be further transferred or 
     reused in violation of such agreement; and
       (v) the transfer otherwise meets the requirements and 
     standards prescribed by the Federal Trade Commission.
       (B) Treatment of public health reporting.--Nothing in this 
     paragraph shall be construed as prohibiting or limiting the 
     use of health care information of an individual, including an 
     individual who is an IHRT participant, for public health 
     reporting (or other research) purposes prior to the inclusion 
     of such information in an electronic health record maintained 
     by an IHRT.
       (4) Law enforcement clarification.--Nothing in this 
     subtitle shall prevent an IHRT from disclosing information 
     contained in an electronic health record maintained by the 
     IHRT when required for purposes of a lawful investigation or 
     official proceeding inquiring into a violation of, or failure 
     to comply with, any criminal or civil statute or any 
     regulation, rule, or order issued pursuant to such a statute.
       (5) Rule of construction.--Nothing in this section shall be 
     construed to require a health care provider that does not 
     utilize electronic methods or appropriate levels of health 
     information technology on the date of the enactment of this 
     Act to adopt such electronic methods or technology as a 
     requirement for participation or compliance under this 
     subtitle.
       (b) Privacy Protection Agreement; Treatment of State 
     Privacy and Security Laws.--
       (1) Privacy protection agreement.--A privacy protection 
     agreement described in this subsection is an agreement, with 
     respect to an electronic health record of an IHRT participant 
     to be maintained by an independent health record trust, 
     between the participant and the trust--
       (A) that is consistent with the standards described in 
     subsection (a)(2);
       (B) under which the participant specifies the portions of 
     the record that may be accessed, under what circumstances 
     such portions may be accessed, any authorizations for 
     indicated authorized EHR data users to access information 
     contained in the record, and the purposes for which the 
     information (or portions of the information) in the record 
     may be used;
       (C) which provides a process for the authorization of the 
     transfer of information contained in the record to a third 
     party, including for the sale of such information for 
     purposes of research, by an authorized EHR data user and 
     reuse of such information by such third party, including a 
     provision requiring that such transfer and reuse is not in 
     violation of any privacy or transfer restrictions placed by 
     the participant on the independent health record of such 
     participant; and
       (D) under which the trust provides assurances that the 
     trust will not transfer, disclose, or provide access to the 
     record (or any portion of the record) in violation of the 
     parameters established in the agreement or to any person or 
     entity who has not agreed to use and transfer such record (or 
     portion of such record) in accordance with such agreement.
       (2) Treatment of state laws.--
       (A) In general.--Except as provided under subparagraph (B), 
     the provisions of a privacy protection agreement entered into 
     between an IHRT and an IHRT participant shall preempt any 
     provision of State law (or any State regulation) relating to 
     the privacy and confidentiality of individually identifiable 
     health information or to the security of such health 
     information.
       (B) Exception for privileged information.--The provisions 
     of a privacy protection agreement shall not preempt any 
     provision of State law (or any State regulation) that 
     recognizes privileged communications between physicians, 
     health care practitioners, and patients of such physicians or 
     health care practitioners, respectively.
       (C) State defined.--For purposes of this section, the term 
     ``State'' has the meaning given such term when used in title 
     XI of the Social Security Act, as provided under section 
     1101(a) of such Act (42 U.S.C. 1301(a)).

     SEC. 847. VOLUNTARY NATURE OF TRUST PARTICIPATION AND 
                   INFORMATION SHARING.

       (a) In General.--Participation in an independent health 
     record trust, or authorizing access to information from such 
     a trust, is voluntary. No employer, health insurance issuer, 
     group health plan, health care provider, or other person may 
     require, as a condition of employment, issuance of a health 
     insurance policy, coverage under a group health plan, the 
     provision of health care services, payment for such services, 
     or otherwise, that an individual participate in, or authorize 
     access to information from, an independent health record 
     trust.
       (b) Enforcement.--The penalties provided for in subsection 
     (a) of section 1177 of the Social Security Act (42 U.S.C. 
     1320d-6) shall apply to a violation of subsection (a) in the 
     same manner as such penalties apply to a person in violation 
     of subsection (a) of such section.

     SEC. 848. FINANCING OF ACTIVITIES.

       (a) In General.--Except as provided in subsection (b), an 
     IHRT may generate revenue to pay for the operations of the 
     IHRT through--
       (1) charging IHRT participants account fees for use of the 
     trust;
       (2) charging authorized EHR data users for accessing 
     electronic health records maintained in the trust;
       (3) the sale of information contained in the trust (as 
     provided for in section 846(a)(3)(A)); and
       (4) any other activity determined appropriate by the 
     Federal Trade Commission.
       (b) Prohibition Against Access Fees for Health Care 
     Providers.--For purposes of providing incentives to health 
     care providers to access information maintained in an IHRT, 
     as authorized by the IHRT participants involved, the IHRT may 
     not charge a fee for services specified by the IHRT. Such 
     services shall include the transmittal of information from a 
     health care provider to be included in an independent 
     electronic health record maintained by the IHRT (or 
     permitting such provider to input such information into the 
     record), including the transmission of or access to 
     information described in section 846(a)(2)(C)(ii) by 
     appropriate emergency responders.
       (c) Required Disclosures.--The sources and amounts of 
     revenue derived under subsection (a) for the operations of an 
     IHRT shall be fully disclosed to each IHRT participant of 
     such IHRT and to the public.
       (d) Treatment of Income.--For purposes of the Internal 
     Revenue Code of 1986, any revenue described in subsection (a) 
     shall not be included in gross income of any IHRT, IHRT 
     participant, or authorized EHR data user.

     SEC. 849. REGULATORY OVERSIGHT.

       (a) In General.--In carrying out this subtitle, the Federal 
     Trade Commission shall promulgate regulations for independent 
     health record trusts.
       (b) Establishment of Interagency Steering Committee.--
       (1) In general.--The Secretary of Health and Human Services 
     shall establish an Interagency Steering Committee in 
     accordance with this subsection.
       (2) Chairperson.--The Secretary of Health and Human 
     Services shall serve as the chairperson of the Interagency 
     Steering Committee.
       (3) Membership.--The members of the Interagency Steering 
     Committee shall consist of the Attorney General, the 
     Chairperson of the Federal Trade Commission, the Chairperson 
     for the National Committee for Vital and Health Statistics, a 
     representative of the Federal Reserve, and other Federal 
     officials determined appropriate by the Secretary of Health 
     and Human Services.
       (4) Duties.--The Interagency Steering Committee shall 
     coordinate the implementation of this title, including the 
     implementation of policies described in subsection (d) based 
     upon the recommendations provided under such subsection, and 
     regulations promulgated under this subtitle.
       (c) Federal Advisory Committee.--
       (1) In general.--The National Committee for Vital and 
     Health Statistics shall serve as an advisory committee for 
     the IHRTs. The membership of such advisory committee shall 
     include a representative from the Federal Trade Commission 
     and the chairperson of the Interagency Steering Committee. 
     Not less than 60 percent of such membership shall consist of 
     representatives of nongovernment entities, at least one of 
     whom shall be a representative from an organization 
     representing health care consumers.
       (2) Duties.--The National Committee for Vital and Health 
     Statistics shall issue periodic reports and review policies 
     concerning IHRTs based on each of the following factors:
       (A) Privacy and security policies.
       (B) Economic progress.
       (C) Interoperability standards.
       (d) Policies Recommended by Federal Trade Commission.--The 
     Federal Trade Commission, in consultation with the National 
     Committee for Vital and Health Statistics, shall recommend 
     policies to--
       (1) provide assistance to encourage the growth of 
     independent health record trusts;
       (2) track economic progress as it pertains to operators of 
     independent health records trusts and individuals receiving 
     nontaxable income with respect to accounts;
       (3) conduct public education activities regarding the 
     creation and usage of the independent health records trusts;
       (4) establish standards for the interoperability of health 
     information technology to ensure that information contained 
     in such record may be shared between the trust involved, the 
     participant, and authorized EHR data users, including for the 
     standardized collection and transmission of individual health 
     records (or portions of such records) to authorized EHR data 
     users through a common interface and for the portability of 
     such records among independent health record trusts; and
       (5) carry out any other activities determined appropriate 
     by the Federal Trade Commission.

[[Page 32817]]

       (e) Regulations Promulgated by Federal Trade Commission.--
     The Federal Trade Commission shall promulgate regulations 
     based on, at a minimum, the following factors:
       (1) Requiring that an IHRT participant, who has an 
     electronic health record that is maintained by an IHRT, be 
     notified of a security breech with respect to such record, 
     and any corrective action taken on behalf of the participant.
       (2) Requiring that information sent to, or received from, 
     an IHRT that has been designated as high-risk should be 
     authenticated through the use of methods such as the periodic 
     changing of passwords, the use of biometrics, the use of 
     tokens or other technology as determined appropriate by the 
     council.
       (3) Requiring a delay in releasing sensitive health care 
     test results and other similar information to patients 
     directly in order to give physicians time to contact the 
     patient.
       (4) Recommendations for entities operating IHRTs, including 
     requiring analysis of the potential risk of health 
     transaction security breeches based on set criteria.
       (5) The conduct of audits of IHRTs to ensure that they are 
     in compliance with the requirements and standards established 
     under this subtitle.
       (6) Disclosure to IHRT participants of the means by which 
     such trusts are financed, including revenue from the sale of 
     patient data.
       (7) Prevention of certification of an entity seeking 
     independent heath record trust certification based on--
       (A) the potential for conflicts between the interests of 
     such entity and the security of the health information 
     involved; and
       (B) the involvement of the entity in any activity that is 
     contrary to the best interests of a patient.
       (8) Prevention of the use of revenue sources that are 
     contrary to a patient's interests.
       (9) Public disclosure of audits in a manner similar to 
     financial audits required for publicly traded stock 
     companies.
       (10) Requiring notification to a participating entity that 
     the information contained in such record may not be 
     representative of the complete or accurate electronic health 
     record of such account holder.
       (f) Compliance Report.--Not later than 1 year after the 
     date of the enactment of this Act, and annually thereafter, 
     the Commission shall submit to the Committee on Health, 
     Education, Labor, and Pensions and the Committee on Finance 
     of the Senate and the Committee on Energy and Commerce and 
     the Committee on Ways and Means of the House of 
     Representatives, a report on compliance by and progress of 
     independent health record trusts with this subtitle. Such 
     report shall describe the following:
       (1) The number of complaints submitted about independent 
     health record trusts, which shall be divided by complaints 
     related to security breaches, and complaints not related to 
     security breaches, and may include other categories as the 
     Interagency Steering Committee established under subsection 
     (b) determines appropriate.
       (2) The number of enforcement actions undertaken by the 
     Commission against independent health record trusts in 
     response to complaints under paragraph (1), which shall be 
     divided by enforcement actions related to security breaches 
     and enforcement actions not related to security breaches and 
     may include other categories as the Interagency Steering 
     Committee established under subsection (b) determines 
     appropriate.
       (3) The economic progress of the individual owner or 
     institution operator as achieved through independent health 
     record trust usage and existing barriers to such usage.
       (4) The progress in security auditing as provided for by 
     the Interagency Steering Committee council under subsection 
     (b).
       (5) The other core responsibilities of the Commission as 
     described in subsection (a).
       (g) Interagency Memorandum of Understanding.--The 
     Interagency Steering Committee shall ensure, through the 
     execution of an interagency memorandum of understanding, 
     that--
       (1) regulations, rulings, and interpretations issued by 
     Federal officials relating to the same matter over which 2 or 
     more such officials have responsibility under this subtitle 
     are administered so as to have the same effect at all times; 
     and
       (2) the memorandum provides for the coordination of 
     policies related to enforcing the same requirements through 
     such officials in order to have coordinated enforcement 
     strategy that avoids duplication of enforcement efforts and 
     assigns priorities in enforcement.

                        TITLE IX--MISCELLANEOUS

     SEC. 901. HEALTH CARE CHOICE FOR VETERANS.

       Beginning not later than 2 years after the date of the 
     enactment of this Act, the Secretary of Veterans Affairs 
     may--
       (1) permit veterans, and survivors and dependents of 
     veterans, who are eligible for health care and services under 
     the laws administered by the Secretary to receive such care 
     and services through such non-Department of Veterans Affairs 
     providers and facilities as the Secretary may approve for 
     purposes of this section; and
       (2) pursuant to such procedures as the Secretary of Veteran 
     Affairs shall prescribe for purposes of this section, make 
     payments to such providers and facilities for the provision 
     of such care and services to veterans, and such survivors and 
     dependents, at such rates as the Secretary may specify in 
     such procedures and in such manner so that the Secretary 
     ensures that the aggregate payments made by the Secretary to 
     such providers and facilities do not exceed the aggregate 
     amounts which the Secretary would have paid for such care and 
     services if this section had not been enacted.

     SEC. 902. HEALTH CARE CHOICE FOR INDIANS.

       (a) In General.--Beginning not later than 2 years after the 
     date of enactment of this Act, the Secretary of Health and 
     Human Services shall--
       (1) permit Indians who are eligible for health care and 
     services under a health care program operated or financed by 
     the Indian Health Service or by an Indian Tribe, Tribal 
     Organization, or Urban Indian Organization (and any such 
     other individuals who are so eligible as the Secretary may 
     specify), to receive such care and services through such non- 
     Indian Health Service, Indian Tribe, Tribal Organization, or 
     Urban Indian Organization providers and facilities as the 
     Secretary shall approve for purposes of this section; and
       (2) pursuant to such procedures as the Secretary of Health 
     and Human Services shall prescribe for purposes of this 
     section, make payments to such providers and facilities for 
     the provision of such care and services to Indians and 
     individuals described in paragraph (1), at such rates as the 
     Secretary shall specify in such procedures and in such manner 
     so that the Secretary ensures that the aggregate payments 
     made by the Secretary to such providers and facilities do not 
     exceed the aggregate amounts which the Secretary would have 
     paid for such care and services if this section had not been 
     enacted.
       (b) Definitions.--In this section, the terms ``Indian'', 
     ``Indian Health Program'', ``Indian Tribe'', ``Tribal 
     Organization'', and ``Urban Indian Organization'' have the 
     meanings given those terms in section 4 of the Indian Health 
     Care Improvement Act.

     SEC. 903. TERMINATION OF FEDERAL COORDINATING COUNCIL FOR 
                   COMPARATIVE EFFECTIVENESS RESEARCH.

       The Federal Coordinating Council for Comparative 
     Effectiveness Research is hereby terminated and section 804 
     of the American Recovery and Reinvestment Act of 2009 
     establishing and funding such Council is hereby repealed.

     SEC. 904. HHS AND GAO JOINT STUDY AND REPORT ON COSTS OF THE 
                   5 MEDICAL CONDITIONS THAT HAVE THE GREATEST 
                   IMPACT.

       (a) Study.--The Secretary of Health and Human Services (in 
     this section referred to as the ``Secretary'') and the 
     Comptroller General of the United States (in this section 
     referred to as the ``Comptroller General'') shall jointly 
     conduct a study on the costs of the top 5 medical conditions 
     facing the public which have the greatest impact in terms of 
     morbidity, mortality, and financial cost. Such study shall 
     include--
       (1) current estimates as well as a ``generational score'' 
     to capture the financial cost and health toll certain medical 
     conditions will inflict on the baby boomer generation and on 
     other individuals; and
       (2) a careful review of certain medical conditions, 
     including heart disease, obesity, diabetes, stroke, cancer, 
     Alzheimers, and other medical conditions the Secretary and 
     Comptroller General determine appropriate.
       (b) Report.--Not later than 1 year after the date of 
     enactment of this Act, the Secretary and the Comptroller 
     General shall jointly submit to Congress a report containing 
     the results of the study conducted under subsection (a), 
     together with recommendations for such legislation and 
     administrative action as the Secretary and the Comptroller 
     General determine appropriate.
       (c) Targeting of Prevention and Wellness Efforts.--The 
     Secretary shall target prevention and wellness efforts 
     conducted under the provisions of and amendments made by this 
     Act in order to combat medical conditions identified in the 
     report submitted under subsection (b), including such medical 
     conditions identified as the top 5 medical conditions facing 
     the public which have the greatest impact in terms of 
     morbidity, mortality, and financial cost as of or after the 
     date of enactment of this Act.

     SEC. 905. CONSCIENCE PROTECTION.

       (a) In General.--None of the funds made available in this 
     Act (or an amendment made by this Act) may be made available 
     to a Federal agency or program, or to a State or local 
     government, if such agency, program, or government subjects 
     any institutional or individual health care entity to 
     discrimination on the basis that the health care entity does 
     not provide, pay for, provide coverage of, or refer for 
     abortions.
       (b) Health Care Entity.--In this section, the term ``health 
     care entity'' shall include an individual physician or other 
     health care professional, a hospital, a provider-sponsored 
     organization, a health maintenance organization, a health 
     insurance plan, or any other kind of health care facility, 
     organization, or plan.

[[Page 32818]]



     SEC. 906. NONDISCRIMINATION ON ABORTION AND RESPECT FOR 
                   RIGHTS OF CONSCIENCE.

       (a) Nondiscrimination.--A Federal agency or program, and 
     any State or local government, or institutional health care 
     entity that receives Federal financial assistance under this 
     Act (or an amendment made by this Act), shall not--
       (1) subject any individual or institutional health care 
     entity to discrimination; or
       (2) require any health care entity that is established or 
     regulated under this Act (or an amendment made by this Act) 
     to subject any individual or institutional health care entity 
     to discrimination;
     on the basis that such health care entity does not provide, 
     pay for, provide coverage of, or refer for abortions.
       (b) Definition.--In this section, the term ``health care 
     entity'' includes an individual physician or other health 
     care professional, a hospital, a provider-sponsored 
     organization, a health maintenance organization, a health 
     insurance plan, a plan sponsor, a health insurance issuer, a 
     qualified health plan or issuer offering such a plan, or any 
     other kind of health care facility, organization, or plan.
       (c) Administration.--The Office for Civil Rights of the 
     Department of Health and Human Services is designated to 
     receive complaints of discrimination based on this section, 
     and coordinate the investigation of such complaints.

     SEC. 907. PROHIBITION ON GOVERNMENT ENTITIES USING 
                   COMPARATIVE EFFECTIVENESS RESEARCH FOR CERTAIN 
                   PURPOSES.

       Comparative effectiveness research and clinical 
     effectiveness research shall not be used by any government 
     entity for payment, coverage, or treatment decisions based on 
     costs. Nothing in the preceding sentence shall limit a 
     physician or other health care provider from using reports 
     and recommendations of a government entity when making 
     decisions about the best treatment for an individual patient 
     in an individual circumstance.

     SEC. 908. SOLVENCY OF MEDICARE PROGRAM.

       Any savings achieved under the Medicare program pursuant to 
     the measures developed and implemented by the Secretary of 
     Health and Human Services under this Act (or an amendment 
     made by this Act) shall be reinvested into the Federal 
     Hospital Insurance Trust Fund, as established under section 
     1817 of the Social Security Act (4218 U.S.C. 1395i), or the 
     Federal Supplementary Medical Insurance Trust Fund, as 
     established under section 1841 of such Act (42 U.S.C. 1395t).

     SEC. 909. TO ENSURE PATIENTS RECEIVE DOCTOR RECOMMENDATIONS 
                   FOR PREVENTIVE HEALTH SERVICES, INCLUDING 
                   MAMMOGRAMS AND CERVICAL CANCER SCREENING, 
                   WITHOUT INTERFERENCE FROM GOVERNMENT OR 
                   INSURANCE COMPANY.

       (a) In General.--Notwithstanding any other provision of 
     law, the Secretary of Health and Human Services shall not use 
     any recommendation made by the United States Preventive 
     Services Task Force to deny coverage of an item or service by 
     a group health plan or health insurance issuer offering group 
     or individual health insurance coverage or under a Federal 
     health care program (as defined in section 1128B(f) of the 
     Social Security Act (42 U.S.C.1320a-7b(f))) or private 
     insurance.
       (b) Determinations of Benefits Coverage.--A group health 
     plan and a health insurance issuer offering group or 
     individual health insurance coverage shall, in determining 
     which preventive items and services to provide coverage for 
     under the plan or coverage, consult the medical guidelines 
     and recommendations of relevant professional medical 
     organizations of relevant medical practice areas (such as the 
     American Society of Clinical Oncology, the American College 
     of Surgeons, the American College of Radiation Oncology, the 
     American College of Obstetricians and Gynecologists, and 
     other similar organizations), including guidelines and 
     recommendations relating to the coverage of women's 
     preventive services (such as mammograms and cervical cancer 
     screenings).

     SEC. 910. ENSURING THAT GOVERNMENT HEALTH CARE RATIONING DOES 
                   NOT HARM, INJURE, OR DENY MEDICALLY NECESSARY 
                   CARE.

       Notwithstanding any other provision of law--
       (1) no individual may be denied health care based on age or 
     life expectancy by any Federal health program; and
       (2) no entity of the Federal Government may develop 
     Quality-Adjusted Life Year measures or other similarly 
     designed government formulas based on an individual's social 
     utility for limiting access to necessary medical treatment.

     SEC. 911. IDENTIFICATION OF FEDERAL GOVERNMENT HEALTH CARE 
                   RATIONING.

       (a) In General.--The Comptroller General of the United 
     States shall conduct, and submit to Congress a report 
     describing the results of, a study that compares, with regard 
     to the programs described in subsection (b)--
       (1) any restrictions or limitations regarding access to 
     health care providers (including the percentage of health 
     care providers willing or permitted to care for patients 
     insured by each program);
       (2) any restrictions, denials, or rationing relating to the 
     provision of health care, including medical procedures, tests 
     (including mammograms and cervical cancer screenings), and 
     prescription drug formularies;
       (3) average wait times to see a primary care doctor;
       (4) average wait times for medically necessary surgeries 
     and medical procedures; and
       (5) the estimated waste, fraud, and abuse (including 
     improper payments) in each program.
       (b) Programs.----The programs referred to in subsection (a) 
     are--
       (1) Medicare;
       (2) Medicaid;
       (3) the Indian Health Service;
       (4) the Department of Veterans Affairs; and
       (5) the Federal Employee Health Benefits Program.

     SEC. 912. USING HEALTH CARE PROFESSIONALS TO REDUCE FRAUD.

       (a) In General.--The Secretary of Health and Human Services 
     (referred to in this section as the ``Secretary'' shall 
     establish a demonstration project that uses practicing health 
     care professionals to conduct undercover investigations of 
     other health care professionals.
       (b) Demonstration Project.--
       (1) In general.--The Secretary, in coordination with the 
     Office of the Inspector General of the Department of Health 
     and Human Services (referred to in this section as the 
     ```Inspector General'''), shall establish a demonstration 
     project in which the Secretary enters into contracts with 
     practicing health care professionals to conduct 
     investigations of health care providers that receive 
     reimbursements through any Federal public health care 
     program.
       (2) Scope.--The Secretary shall conduct the demonstration 
     project under this section in States or regions that have--
       (A) above-average rates of Medicare fraud; or
       (B) any level of Medicaid fraud.
       (c) Eligibility.--To be eligible to receive a contract 
     under subsection (b)(1), a health care professional shall--
       (1) be a licensed and practicing medical professional who 
     holds an advanced medical degree from an accredited American 
     university or college and has experience within the health 
     care industry; and
       (2) submit to the Secretary such information, at such time, 
     and in such manner, as the Secretary may require.
       (d) Activities.--Each health care professional awarded a 
     contract under subsection (b)(1) shall assist the Secretary 
     and the Inspector General in conducting random audits of the 
     practices of health care providers that receive 
     reimbursements through any Federal public health care 
     program. Such audits may include--
       (1) statistically random visits to the practices of such 
     health care providers;
       (2) attempts to purchase pharmaceutical products illegally 
     from such health care providers;
       (3) purchasing durable medical equipment from such health 
     care providers;
       (4) hospital visits; and
       (5) other activities, as the Secretary determines 
     appropriate.
       (e) Follow-up by the Inspector General.--The Inspector 
     General shall follow up on any notable findings of the 
     investigations conducted under subsection (d) in order to 
     report fraudulent practices and refer individual cases to the 
     appropriate State and local authorities.
       (f) Limitation.--The Secretary shall not contract with a 
     health care professional if, due to physical proximity or a 
     personal, familial, proprietary, or monetary relationship 
     with such health care professional to individuals that such 
     professional would be investigating, a conflict of interest 
     could be inferred.
       (g) Funding.--To carry out this section, the Secretary and 
     the Inspector General are each authorized to reserve, from 
     amounts appropriated to the Department of Health and Human 
     Services and the Office of the Inspector General of the 
     Department of Health and Human Services, respectively, 
     $500,000 for each of fiscal years 2010 through 2014.

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